An out-of-pocket maximum is a limit on how much you have to pay during a plan year for covered services under the plan’s applicable rules.
For example, suppose your plan has a $5,000 out-of-pocket maximum.
If you reach that amount through eligible deductibles, copayments, and coinsurance for covered in-network care, the plan generally pays 100% of covered benefits for the remainder of the plan year.
However, an out-of-pocket maximum usually does not include everything you spend.
For example, it generally does not include:
- Your monthly premiums
- Services the plan doesn’t cover
- Certain out-of-network expenses
- Amounts above an allowed amount in applicable situations
Always check the specific policy because the rules can different
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