Out-of-pocket maximum
The annual cap on a patient's cost-sharing for covered in-network services; once reached, the plan pays 100% of allowed amounts.
Updated
The out-of-pocket maximum is the most a patient pays in deductibles, copayments, and coinsurance for covered, in-network services during a plan year. Once the limit is reached, the health plan pays 100% of the allowed amount for covered essential health benefits.
Premiums and charges for non-covered or out-of-network services generally do not count toward the in-network out-of-pocket maximum.
In practice
Billing systems accumulate patient cost-sharing against the out-of-pocket maximum throughout the plan year. Once the threshold is met, claims are processed with zero patient responsibility for covered services, and providers should not bill the patient for those amounts.
Commonly confused with
- Deductible: The deductible is the amount paid before the plan shares cost; the out-of-pocket maximum is the cap beyond which the plan pays 100%.