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What Is My Health Insurance Out-of-Pocket Maximum?
August 22, 2024 | 6 min read
The out-of-pocket maximum is the most your healthcare plan requires you to pay each plan year for care and services you use that are covered by your plan. It is also known as an out-of-pocket limit. After you spend this amount on covered care and services, your plan will pay 100% of the cost of covered benefits.
Understanding how the out-of-pocket maximum works can help you select the right plan for you and your family and get the most value out of your health insurance coverage.
Understanding the Out-of-Pocket Maximum
An out-of-pocket maximum is the total amount your health insurance plan will require you to pay for covered medical care each plan year. If your health insurance plan covers a spouse or dependents, you could have individual and family out-of-pocket limits.
Your out-of-pocket limits will depend on your plan. For 2024, plans available on the Health Insurance Marketplace can have limits as high as $9,450 for an individual and $18,900 for a family, so this is an important detail to look for when you’re shopping for plans.
Here are some important points to know:
- An out-of-pocket maximum is the most you will have to pay for covered, in-network services during the plan year.
- When you reach your maximum, the health plan will cover 100% of qualified expenses.
- Different plans have different out-of-pocket maximums.
- Some of your healthcare expenses may not count toward your out-of-pocket limit.
- You may be able to qualify for savings to help with some of your out-of-pocket costs, depending on your income.
Plans with higher monthly premiums usually have lower out-of-pocket limits. Browse Ambetter Health plans or call our helpful team at 844-933-0380 (TTY: 711) to find a Health Insurance Marketplace plan with an out-of-pocket limit that works for you and your family.
Pro Tip
If you qualify for cost-sharing reductions and you choose a plan in the “silver” category, you may be able to get a lower out-of-pocket max.
Whatever you pay for copays, deductibles and coinsurance for in-network care all count toward your out-of-pocket max. These costs vary depending on your health insurance plan.
Copay
This is a fixed amount you pay for a covered service. It could vary depending on the type of service or provider. Copays typically remain the same throughout your plan year, even after you have met your deductible.
Deductible
This is the amount you pay out of your pocket for covered services before your plan starts to pay. This does not include services covered by copays, and your copay costs usually do not count toward your deductible.
Coinsurance
This is a percentage, often 20%, of covered healthcare costs that you have to pay after you have reached your deductible.
Expenses That Do Not Count Toward Your Out-of-Pocket Maximum
Not all your medical expenses will help you reach your out-of-pocket maximum. The following typically do not go toward your limit:
Monthly premiums
The amount you pay each month to maintain your health insurance plan does not count toward your out-of-pocket maximum.
Out-of-network care and services
Your health plan will provide you with a list of network providers. If you visit doctors or healthcare facilities that are not part of this network, the cost may not count.
Services that are not covered
Your health plan may not cover some types of medical services, such as cosmetic treatments, alternative medicines or weight loss surgery. If you use non-covered services, you will pay in full, and the costs won’t go toward your out-of-pocket limit.
Services paid by your plan in full
Covered preventive services that are paid for by your health plan do not count toward the annual limit because you don’t need to pay anything for them.
How An Out-of-Pocket Maximum Works
During the plan year, whenever you receive covered, in-network healthcare, you will often have to pay certain expenses, such as deductibles, copayments and coinsurance, out of your own pocket. All these costs count toward your out-of-pocket maximum. Once you reach your out-of-pocket maximum, your health plan will pay 100% of your covered, in-network services.
Here is a fictional scenario that should help explain how it could work. This example would vary depending on the health plan.
Bob chose a health insurance plan from the Health Insurance Marketplace. His plan has a:
- $3,000 deductible
- 20% coinsurance
- $6,000 out-of-pocket maximum
After just a few weeks on the plan, Bob gets injured and visits his in-network primary care provider (PCP) as well as a specialist. Both doctors order tests to understand the extent of Bob’s injuries. It’s determined that Bob needs a minor medical procedure, which is preapproved and scheduled at an in-network facility.
For the initial doctor visits and the procedure, total costs are $12,000 after the plan processes the claims. So Bob has to pay:
- Deductible: $3,000
- Coinsurance: 20% of the remaining $9,000, which is $1,800
So Bob’s total out-of-pocket for this event is $4,800.
Bob has now met his deductible, and all of these expenses count toward his $6,000 out-of-pocket max. That means Bob has paid $4,800 of his $6,000 out-of-pocket maximum.
Bob’s Health Insurance Plan Has:
$3,000 Deductible
Bob’s visits, tests and procedure cost
$12,000
Bob pays his deductible
- $3,000
Which leaves
$9,000
20% Coinsurance
Remaining after
deductible
$9,000
Bob also pays 20% of the remaining balance
(20% of $9,000 is $1,800)
- $1,800
The remaining balance is paid by
Bob’s plan.
$7,200
$6,000 Out-of-Pocket
Maximum
The maximum Bob has to pay out-of-pocket
$6,000
Bob's total out-of-pocket so far
($3,000 deductible + $1,800 coinsurance)
- $4,800
Bob’s remaining
out-of-pocket max
$1,200
Now that Bob has met his deductible, he will only have to pay 20% of future covered medical expenses, due to his plan’s 20% coinsurance. His health plan will pay the remaining 80%. This 20/80 split of covered costs will continue until Bob has paid the rest of his $6,000 out-of-pocket max. Once he has done that, Bob’s health plan will pay 100% of covered, in-network care.
The out-of-pocket maximum is an important consideration when you are choosing a health insurance plan. Because plans with low out-of-pocket limits likely have higher premiums, you’ll want to shop plans carefully to find the right balance for your needs.
Shop Ambetter Health plans or call our helpful team at 844-933-0380 (TTY: 711) from 8 a.m. to 9 p.m. ET to find a health insurance plan with the right out-of-pocket max to meet your needs.
Frequently Asked Questions About Out-of-Pocket Maximums
Most health plans have a network of healthcare providers and facilities. If you choose to see a doctor or use a healthcare facility outside of your plan’s network, your plan may not cover those costs. You will have to pay for non-covered services, and those expenses will not count toward your out-of-pocket maximum.
When you use an in-network healthcare provider or facility, you can be confident that these services are within the coverage of your health plan. If you are considering a plan from Ambetter Health, you can use our network guide to check if your doctors and healthcare facilities are in the network.
This is the maximum amount that each person covered on the plan will have to pay during the plan year. If someone on the plan reaches the individual out-of-pocket maximum, the plan should start paying 100% of that person’s covered care for the rest of the plan year although this could vary depending on the plan. Any expenses individuals pay also go toward meeting the family out-of-pocket maximum.
This is the total out-of-pocket maximum for the plan year. Any expenses individuals pay go toward meeting the family out-of-pocket maximum. When the family out-of-pocket max is met, the plan starts paying 100% of covered costs for everyone on the plan.
If you qualify for cost-sharing reductions and you choose a plan in the “silver” category, you may be able to get a lower out-of-pocket max. To see if you qualify for financial assistance when you shop for plans on the Health Insurance Marketplace, select the option to check for subsidies.
Shop Ambetter Health Plans
Find a health insurance plan with the right out-of-pocket max to meet your needs.
Or call our helpful team:
844-933-0380 (TTY: 711)
8 a.m. to 9 p.m. ET
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