What is “Out of Pocket Maximum”???
Your out of pocket maximum is the most you’ll have to pay for covered services in a policy period (one year). After you reach this amount, your health plan will pay 100% for covered “essential health benefits”. This doesn’t count your monthly premiums or services from out-of-network providers.
[updated for 2018]
The maximum out-of-pocket limit for a health insurance plan for 2018 is $7,350 for an individual plan and $14,700 for a family plan.
In 2013 the limits were $6,250 for individuals and $12,700 for families.
Think of it like a game of baseball. Once you’ve paid all of your “deductible“, you are standing on 1st base. Now you’ll begin to move towards 2nd base – “Co-Insurance”. During this time, co-insurance is where you and the insurance company split the medical bills, for example 70/30 or 80/20. Usually the insurance company will pay the larger amount and you pay the lesser amount.
Your next step is 3rd base or your “Out of Pocket Maximum”. Once you’ve met your “out of pocket maximum”, you are now done paying anything else. The insurance company will pick you up on 3rd base, and carry you to home plate.
Note: This is an annual accrual, meaning it starts January 1st and ends December 31st each year.