Who is this for?Anyone under age 65. You share the cost of your care with your health insurance company when you pay your deductible, coinsurance and copays. But did you know there’s a limit to how much you pay? It’s called an out-of-pocket max, or maximum. It’s the most you’ll have to pay during a policy period, usually a year, for health care services. How it worksWhat you pay toward your plan’s deductible, coinsurance and copays are all applied to your out-of-pocket max. Once you reach your out-of-pocket max, your plan pays 100 percent of the allowed amount for covered services. If your plan covers more than one person, you may have a family out-of-pocket max and individual out-of-pocket maximums. That means:
What doesn’t go toward your out-of-pocket max
Dental plans are differentOut-of-pocket maximums for dental plans also limit what you pay in deductible, coinsurance and copays. But dental plans usually only have an out-of-pocket max for members age 19 and younger. The out-of-pocket maximum is a limit on what you pay out on top of your premiums during a policy period for deductibles, coinsurance and copays. Once you reach your out-of-pocket maximum, your health insurance will pay for 100% of most covered health benefits for the rest of that policy period. The next policy period (plan year), it starts all over again - note: the policy year may not coincide with the calendar year. Thinking ahead about the health care services that you may need in the coming year and understanding how out-of-pocket maximums work can help you decide which health plan to enroll in. Learn more. Have you met your out-of-pocket maximum (or are you close)? If you still have time left in your policy period (plan year) and are close to reaching your out-of-pocket maximum, you may want to:
To avoid unexpected costs, remember to review your policy, certificate or plan booklet, get any referrals from your health care provider, and contact your health insurance company about preauthorization before receiving certain health care services and prescriptions. Learn more Not all plans are the same; get to know yours It’s important to know how the out-of-pocket maximum works for your plan:
Generally, once an individual has reached their out-of-pocket maximum most care for that person is covered at 100% ― but, the other family members keep paying. For example, say Bob’s plan has an individual out-of-pocket maximum of $5,000 and family out-of-pocket maximum of $10,000. Bob is the first in his family to reach $5,000 in expenses. Bob won’t need to pay out-of-pocket for deductibles, copays or co-insurance for the rest of the policy year for his care; however, services for his covered spouse and child would be subject to cost sharing until either their individual out-of-pocket maximum is met or the family out-of-pocket maximum is met. There are some plans, called “Catastrophic Plans that have a combined deductible for individuals and family members that all out-of-pocket costs when combined hit the maximum, then expenses are paid by the carrier at 100%,
4/19/2018 |