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What is Out of Pocket Maximum?

If you have health insurance, the most that you will have to pay for covered medical services in a year is your out-of-pocket maximum. Based on the plan you have, “covered services” may be different, and your out of pocket maximum will differ from that of other plans.

Costs That Go Towards Meeting the Out of Pocket Maximum

It’s vital to know what costs you pay out of pocket. Below are some costs that are comprised of many health insurance policies:

• Deductible. Your deductible is the predetermined amount of money you have to spend on qualified medical costs before insurance kicks in and begins contributing to your medical costs. Usually, any expenses that go towards meeting your deductible also go towards your out of pocket maximum.
• Coinsurance. Coinsurance comes as a percentage. With most plans, after you have met your deductible, you and your insurance split the cost of your qualified medical expenses. If your coinsurance is 20%, this means after your deductible is met, you will pay 20% of medical bills, and your insurance organization will pay 80%.
• Copayment. Unlike coinsurance, this is a set rate you pay for medical care at the time that you require it. When you visit the physician or hospital, your plan may have an outlined amount like $40 for office visits and $250 for a hospital visit that you will have to pay.

The predetermined monthly premium that you pay to be covered by your plan does not go towards your maximum out of pocket costs. Even after you have met out of pocket maximum, you will continue paying your monthly premium lest you cancel the plan or change to a new plan during the open enrollment period.

Medical services that you pay for, and which are not covered by your plan, will not count towards your out of pocket maximum.

What Happens after Out of Pocket Maximum is Met?

This is a popular question that comes up, but it is easy to answer if you know the technical definitions for both of these health insurance terms. A copayment is an out of the pocket payment that you make towards standard medical costs such as physician’s office visits or an emergency room visit. An out of pocket maximum is the set amount of money you will have to pay in a year on covered medical expenses. In many plans, there is no copayment for covered medical services once you have met yours out of pocket maximum. All plans are different, though, so be sure to pay attention to plan details when purchasing a plan. If you have already bought a plan, you can look at your copayment details and ensure that you’ll have no copayment to pay after you have met your out of pocket maximum.

In many situations, though, after you’ve met the set limit for out of pocket costs, insurance will be paying for 100% of covered medical expenses.

Does my Out of Pocket Maximum Incorporate my Deductible?

The answer is yes. Again, understanding the definitions for both these terms will help answer questions you have about what is comprised in your out of pocket maximum. Your deductible is the amount that you pay out of pocket, after which your insurance company will begin paying to medical costs. Your out of pocket maximum is a total of everything that you have paid out of pocket for medical services. So, if you had a $400 emergency room visit prior to meeting your deductible, it will help you get close to meeting both that and the out-of-pocket maximum.

Resources and References:

• Composition of Out of Pocket Maximum
• Purchasing an Insurance Plan