Out-of-Pocket Maximum
The most you'll pay for covered services in a plan year, after which insurance pays 100%.
What is Out-of-Pocket Maximum?
The out-of-pocket maximum (also called out-of-pocket limit) is the most you'll have to pay for covered healthcare services in a plan year. Once you reach this amount through deductibles, copays, and coinsurance, your insurance pays 100% of covered services for the rest of the year.
For HSA-qualifying HDHPs in 2024, the maximum out-of-pocket limit is $8,050 for individual coverage and $16,100 for family coverage. Marketplace plans have similar limits set by law.
Your out-of-pocket maximum usually doesn't include your monthly premiums, out-of-network costs, or services your plan doesn't cover. It also resets at the start of each plan year.
Frequently Asked Questions
Do premiums count toward out-of-pocket maximum?
No. Monthly premiums are separate from your out-of-pocket maximum. The max only includes deductibles, copays, and coinsurance.
What happens after I hit my out-of-pocket max?
Your insurance pays 100% of covered services for the rest of the plan year. You only pay your premiums.
Does out-of-pocket maximum include out-of-network care?
Usually not. Many plans have separate (higher) out-of-pocket limits for out-of-network care, or don't cap those costs at all.
Related Terms
Deductible
The amount you must pay out-of-pocket for healthcare before your insurance starts covering costs.
Coinsurance
The percentage of costs you pay for covered healthcare services after meeting your deductible.
Copay (Copayment)
A fixed amount you pay for a covered healthcare service at the time of the visit.
High-Deductible Health Plan (HDHP)
A health insurance plan with a higher deductible and lower premiums that qualifies you to open an HSA.
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