Out-of-pocket maximum

What does Out-of-pocket maximum mean on a medical bill?

The out-of-pocket maximum is the ceiling on what you pay for covered, in-network care in a plan year. Deductible, copays, and coinsurance count toward it; premiums do not, and neither do services your plan never covered. Once you hit it, the plan is supposed to pay the full allowed amount for covered care for the rest of the year. Family coverage usually has two ceilings, one for each person and a larger one for everyone together.

What does Out-of-pocket maximum usually cost?

Hitting it does not stop every bill. Care the plan treats as not covered, and out-of-network charges on many plans, keep landing on you afterward, which is why the EOB matters more than the running total in the app.

What should I watch out for with Out-of-pocket maximum?

• Cost sharing still billed after the EOB shows the maximum was reached — ask the plan to reprocess
• Ask your plan which of your bills counted toward it, since non-covered services usually do not
• One person in a family plan hitting the individual ceiling while bills keep coming — ask how the plan applies it