Bills and insurance
What Is an Out-of-Pocket Maximum?
Out-of-Pocket Maximum · say it: out-of-POK-it MAK-sih-mumAlso written: OOP max, out-of-pocket limit, maximum out-of-pocket, MOOP
Short answer
The out-of-pocket maximum is the most you pay for covered, in-network care in a plan year; after that, the plan pays 100 percent of covered services.
What it means
Your deductible, copays and coinsurance for covered services add up through the year. Once that total reaches the out-of-pocket maximum, the plan pays the full allowed amount for covered care for the rest of the plan year.
Monthly premiums do not count toward it. Out-of-network care, services the plan does not cover, and charges above the allowed amount often do not count either, depending on the plan.
The limit resets at the start of each plan year. Family plans often have individual and family maximums.
Where you may see it
- Insurance plan summaries
- Explanation of benefits (EOB) statements
- Year-to-date benefit summaries
📄 How it looks on a report
Out-of-pocket max: $4,000.00. Met to date: $3,250.00
🙅 What it does not mean
- Reaching the maximum does not mean everything is free; uncovered and some out-of-network services may still cost you.
- Premiums do not count toward the out-of-pocket maximum.
- It is not a one-time limit; it resets each plan year.
🗒️ Questions to ask your doctor
🧾 Reports where you will see “Out-of-Pocket Maximum”
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🔗 Read more from trusted sources
- “Out-of-Pocket Maximum” on MedlinePlus ↗
US National Library of Medicine
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