What is an out-of-pocket maximum, and which costs typically count toward it?

• A. The maximum amount a insured pays in a year for covered services; deductibles, copays, and coinsurance typically count toward the OOP max, while premiums generally do not.
• B. The maximum amount a insured pays in a lifetime.
• C. The maximum annual premium.
• D. The maximum allowed charges by providers.

Answer: (A)

An out-of-pocket maximum is the most you’ll pay in a plan year for covered healthcare services. Once you reach that cap, the plan pays 100% of the costs for covered services for the rest of the year. Costs that count toward this limit are the amounts you pay as part of cost sharing: deductibles, copays, and coinsurance. Premiums, the regular payments to maintain your coverage, do not count toward the out-of-pocket maximum. Some plans may exclude certain amounts or non-covered services from counting toward the limit, and out-of-network charges may be treated differently depending on the plan.