Out-of-pocket max

Your out-of-pocket max is the most you could pay for covered health care in a calendar year aside from your monthly premium. It's there to protect your finances from big medical bills.

Depending on your plan, you may pay for some of your own care until you meet your deductible (opens in new tab), or you might pay part of the bill in copays (opens in new tab) or coinsurance (opens in new tab). But once your spending over the course of the year reaches your plan's max, your health insurance plan begins paying 100% for covered services as long as you get care in-network.

There are no annual limits to how much we'll cover if you're sick or injured, and in a world where a single injury or illness could rack up thousands of dollars in medical bills, your out-of-pocket max is there to protect your finances.

How much is an out-of-pocket max?

Your max varies depending on your plan (opens in new tab). Gold and Platinum plans have higher premiums (opens in new tab) but lower out-of-pocket maximums. Bronze, Silver, and catastrophic plans have lower premiums but higher out-of-pocket maximums.

If you qualify, government subsidies (opens in new tab) can lower your out-of-pocket max for certain Silver plans.

Why is my out-of-pocket max important?

Your out-of-pocket max usually comes into play if you have a serious or unexpected health issue where costs can quickly get out of control. Say, for example, you need to have your appendix removed. Without insurance, you might have to pay $55,000 to get the care you need. But with even the most basic individual health insurance plan, you’d pay $6,850 at most in medical expenses on top of your monthly premiums. Yes, $6,850 is a lot of money, but it’s a lot less than what you’d have to pay without health insurance.

How does an out-of-pocket max work?

Let’s break it down using the above example. Imagine your plan looks like this:

• Your deductible is $3,000.
• Your coinsurance is 20%.
• Your out-of-pocket max is $4,000.
• Your monthly premium is $524.

For a $55,000 surgery, you’d pay the following:

• Your deductible of $3,000.
• Your 20% coinsurance on the remaining amount ($52,000) would be $10,400. However, because your out-of-pocket max kicks in at $4,000, you’d actually only pay $1,000. Your plan will then pay the rest of the bill ($51,000).

So all told, you’d pay $4,000 (that's $3,000 for your deductible, plus $1,000 in coinsurance). You’d also continue to pay your premium of $524 per month.

Are there any exceptions where I’ll owe money other than my premium after I’ve reached my max?

Yes, your max does not take into account services not covered by your plan. These include the following:

• Out-of-network services. If you see a doctor who is not in-network, you’ll have to pay 100% of the cost unless it’s considered an emergency (in which case, it’s treated by your insurer as an in-network service).
• Elective services. Elective procedures like cosmetic surgeries are not considered “medically necessary.” Read through your plan carefully to find out what’s covered by your insurer and what’s not.
• Adult dental or vision care. These services aren’t typically covered by individual health insurance plans. However, you can shop for separate dental and vision plans on the health care marketplace.