What Counts Toward the Out-of-Pocket Maximum?
Deductibles, coinsurance, and copays for covered in-network care usually count. Premiums, out-of-network bills, and non-covered services usually don't. Here's a checklist.
Quick answer
Usually counts: deductible payments, coinsurance, and copays for covered, in-network services. Usually doesn't count: premiums, non-covered services, out-of-network costs on many plans, and balance bills above what the plan allows.
Checklist
| Cost | Counts toward the out-of-pocket maximum? |
|---|---|
| Deductible for covered in-network care | Usually yes |
| Coinsurance for covered in-network care | Usually yes |
| Copays for covered in-network care | Usually yes |
| Covered prescription drug cost sharing | Usually yes on most plans |
| Monthly premiums | No |
| Services the plan doesn't cover | No |
| Out-of-network care | Often no, or counts toward a separate out-of-network maximum |
| Balance billing above the allowed amount | No |
Family plans
Family plans usually have an individual maximum and a family maximum. Once one person reaches the individual amount, their covered care is paid in full, even if the family total hasn't been reached.
Medicare
Original Medicare has no out-of-pocket maximum. Medicare Advantage plans have one for covered Part A and B services; Part D has its own annual cap; see Part D coverage phases.
See what is an out-of-pocket maximum.
The takeaway
Only cost sharing for covered, in-network care usually counts. Staying in-network and checking coverage first keeps your spending inside the protection the maximum provides.
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