GLOSSARY · INSURANCE
Out-of-pocket maximum
The most a health plan can make you pay in a plan year for covered, in-network care through deductibles, copays and coinsurance. Once you reach it, the plan pays the full negotiated price of covered in-network care for the rest of the year. Premiums, uncovered services and most out-of-network care do not count toward it. Federal law caps it for most plans, and a lower cap applies to plans that qualify for a Health Savings Account.
Also called: out-of-pocket limit, OOP max, maximum out of pocket, annual limitation on cost sharing, MOOP
FORMULA
Worst-case yearly cost of a plan = premiums for the year + out-of-pocket maximum
COMPUTE IT WITH YOUR NUMBERS
LEARN IT PROPERLY
CHAPTER · INSURANCE PROTECTION ESSENTIALS · FOUNDATIONSBuilding a Cash Safety Net Under Your InsuranceCHAPTER · INSURANCE PROTECTION ESSENTIALS · FOUNDATIONSHealth Insurance and the Health Savings AccountRELATED TERMS
SOURCES
- Out-of-pocket maximum/limit (glossary). HealthCare.gov, Centers for Medicare & Medicaid Services.