Out-of-Pocket Maximum

Plain English Definition: The most you have to pay for covered services in a plan year.

What Out-of-Pocket Maximum really means for someone with an insurance policy

It limits the total amount you’ll spend on healthcare costs in a year. After reaching this amount, your insurance covers 100% of eligible expenses.

Out-of-Pocket Maximum Real World Examples

• After paying $5,000 out of pocket, your insurance covers all future costs for the year.
• If your out-of-pocket maximum is $3,000, your insurer pays 100% after you hit that amount.
• This cap helps prevent unexpected financial burdens from major medical events.