What Is an Out-of-Pocket Maximum in Health Insurance?
The out-of-pocket maximum is the most you'd pay for covered in-network care in a plan year. After you reach it, the plan pays 100% of covered in-network costs. Premiums don't count.
Quick answer
The out-of-pocket maximum is the most you'll pay for covered, in-network care in a plan year through deductibles, copays, and coinsurance. Once you reach it, the plan pays 100% of covered in-network costs for the rest of the year. Premiums don't count toward it.
How it works
A hypothetical plan: $1,500 deductible, 20% coinsurance, $4,000 out-of-pocket maximum. A $50,000 hospital stay:
Show the numbers behind this chart
| Amount | |
|---|---|
| You pay | $4,000 |
| Plan pays | $46,000 |
Why it matters
The out-of-pocket maximum is your worst-case cost for covered care, so premiums plus the maximum is the right number for comparing plans in a bad year. See comparing health plans by total cost and what counts toward the out-of-pocket max.
The takeaway
Know your out-of-pocket maximum. It's the ceiling on what a covered medical emergency could cost you in a year, aside from premiums.
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