Out-of-Pocket Maximum
Insurance Glossary
The most a member pays for covered in-network care in a plan year, after which the plan pays 100 percent of covered services for the rest of that year. Deductibles, copays and coinsurance count toward it, while monthly premiums, charges above the allowed amount and anything the plan does not cover do not. Federal rules cap it for Affordable Care Act plans and the cap is adjusted each year, and family policies carry both an individual and a family limit.
This content is for general informational purposes only and is not insurance, legal, or financial advice. Coverage, exclusions, eligibility, and pricing vary by insurer, by policy, and by state, and only the policy documents control what is covered. Always confirm the details of any coverage with a licensed insurance agent or the issuing carrier before you buy.