The out-of-pocket maximum is the most you have to pay for covered medical services in a year. Generally, it includes any applicable deductible, copayments, and/or coinsurance.
Here’s how the out-of-pocket maximum works if you have family coverage:
It Depends on Your Medical Coverage Level
The Bronze, Silver, Gold, and Platinum coverage levels have a traditional out-of-pocket-maximum.
Once a covered family member meets the individual out-of-pocket maximum, your insurance will pay the full cost of covered charges for that family member.
Charges for all covered family members will continue to count toward the family out-of-pocket maximum. Once the family out-of-pocket maximum is met, your insurance will pay the full cost of covered services for any covered family member (subject to the allowed amount limitation for out-of-network services).
The annual out-of-pocket maximum doesn't include amounts taken out of your paycheck for health coverage or certain copays under the Silver, Gold, and Platinum options.
It also doesn't include amounts above the "allowed amount," which is the most your insurance carrier will pay for a covered service.
The Bronze Plus coverage level has a "true family out-of-pocket maximum." This means that the entire family out-of-pocket maximum must be met before your insurance will pay the full cost of covered charges for any covered family member (subject to the allowed amount limitation for out-of-network services).
There is no "individual out-of-pocket maximum" in this plan when you have family coverage.
The annual out-of-pocket maximum doesn't include amounts taken out of your paycheck for health coverage. It also doesn't include amounts above the "allowed amount," which is the most your insurance carrier will pay for a covered service or amounts for services that are not covered.
Do You Use Out-of-Network Providers?
Out-of-network charges will not count toward your in-network deductible or in-network out-of-pocket maximum. The same goes for in-network charges—they will not count toward your out-of-network deductible or out-of-network out-of-pocket maximum.
And some insurance carriers in CA, CO, DC, GA, MD, OR, VA, and WA do not cover out-of-network benefits at all.
Out-of-network benefits are available for emergency care.
Important note about in-network out-of-pocket maximums versus out-of-network out-of-pocket maximums:
- In-Network Out-of-Pocket Maximum. Once you have reached your annual in-network out-of-pocket maximum, your insurance carrier will generally pay 100% for any covered in-network service or supply provided to you for the balance of the coverage year, subject to age and frequency limits.
- Out-of-Network Out-of-Pocket Maximum. The annual out-of-network out-of-pocket maximum works differently. It does not limit what you pay for charges that exceed the "allowed amount"—that is, the maximum amount the insurance carrier allows for a covered service or supply. This means that even after you reach your annual out-of-network out-of-pocket maximum, you will continue to be responsible for paying the full amount of any out-of-network service or supply charge above the allowed amount.