What Is An Out-of-Pocket Maximum – When Will My Insurance Step In?

2021 – The maximum out-of-pocket limit for a health insurance plan for 2021 is $8,550 for an individual plan and $17,100 for a family plan. 

2022 – In 2022 it is $8,700 for an individual plan and $17,400 for a family plan. 

2023 – For 2023 it will be is $9,100 for an individual plan and $18,200 for a family plan.

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Each plan can have a lower out-of-pocket maximum, these numbers are the worst-case scenario. Check your plans “Summary of Benefits” for details.

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), each January 1st it starts over again, and that includes cost of medications too. After you reach this amount, your health insurance plan will pay 100% for covered benefits called “essential healthcare benefits”. Your out-of-pocket costs are NOT your health insurance premiums. Your monthly premiums are totally separate and are in addition to your medical costs like co-pays, deductibles, and out of pocket maximums.

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 (co-insure), for example 70/30 or 80/20.  Usually, the insurance company will pay the larger amount and you’ll 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 (they are responsible for unlimited coverage after your out of pocket maximum).

Note:  This is an annual accrual, meaning it starts January 1st and ends December 31st each year.

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It is hard to budget for health expenses when you do not know what your cost-sharing responsibility will be.  At Nevada Insurance Enrollment, our health insurance agents can help you review your policy or find reliable health coverage.

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What Are Essential Health Benefits And Who Has To Have Them?

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Read More: Health Insurance in Las Vegas, Nevada

 

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