What is the out-of-pocket maximum?

• A. The maximum amount a member pays for the entire policy year, after which the insurer pays 100% of covered services.
• B. The total premium due each year.
• C. The maximum lifetime cost for a member.
• D. The limit on annual deductible only.

Answer: (A)

The out-of-pocket maximum is the cap on what you pay for covered health care services in a policy year. Once you reach that limit, the plan covers 100% of the cost of covered services for the rest of the year. It typically includes amounts you’ve paid toward the deductible, coinsurance, and copays, but does not include your premiums, and doesn’t apply to services that aren’t covered. This protection helps guard against very high medical bills. The other choices describe different concepts: premiums are the yearly payments to keep the policy active, not the cap on costs; a lifetime maximum is a total cap over a person’s lifetime, not per year; and the deductible limit alone is just one part of costs and doesn’t reflect the full annual cap.