What is Out-of-pocket maximum/limit?
Out-of-pocket maximum/limit meaning
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.
The out-of-pocket limit doesn’t include your monthly premiums. It also doesn’t include anything you spend for services your plan doesn’t cover.
- For the 2017 plan year: The out-of-pocket limit for a Marketplace plan is $7,150 for an individual plan and $14,300 for a family plan.
- For the 2016 plan year: The out-of-pocket limit for a 2016 Marketplace plan is $6,850 for an individual plan and $13,700 for a family plan.
Example of out-of-pocket maximum with high medical costs
Let’s say you need surgery with allowable costs of $20,000, and the following figures apply to your health insurance plan.
You pay the first $1,300 of covered medical expenses (your deductible).
Your 20% coinsurance on the rest of the costs ($18,700) comes to $3,740.
So your total costs would be $5,040. That’s $1,300 (your deductible) plus $3,740 (coinsurance).
But your out-of-pocket maximum is $4,400. Your insurance company pays all covered costs above $4,400