Frequently Asked Questions

What is an out-of-pocket maximum?

A health insurance policy's out-of-pocket-maximum (OOPM) is the limit on the total coinsurance and deductible you will pay in any calendar year.  Once the OOPM is reached for a calendar year, the plan pays 100% of covered expenses for the rest of the year. For instance, if your plan has a $1,000 deductible and a $2,000 OOPM, you will pay $1,000 before the plan starts paying a portion of covered expenses. If your coinsurance is 20%, you will pay 20% of the remainder of covered expenses until you have spent an additional $1,000. Before you spend this additional $1,000, the plan is still paying 80% of covered expenses. But after you've spent $1,000 in coinsurance, you will have spent $1,000 toward the deductible and $1,000 in coinsurance. You are now completely covered, because $1,000 plus $1,000 equals your OOPM of $2,000. After reaching your OOPM, you no longer pay any coinsurance because the plan begins paying 100% of covered expenses.

« Back to questions