What is the out-of-pocket maximum?

• A. The fixed fee per visit.
• B. The most you have to pay for covered services in a plan year.
• C. The portion of costs you pay after deductible.
• D. The total premium paid each month.

Answer: (B)

The out-of-pocket maximum is the most you have to pay for covered health care services in a plan year. It acts as a cap on your spending: what you’ve paid toward the deductible, plus your copayments and coinsurance for covered services, all count toward this limit. Once you reach that maximum, the plan pays 100% of the cost of covered services for the rest of the plan year. It does not include your monthly premiums or costs for services not covered by the plan, and some plans have separate limits for in-network versus out-of-network care. This protection helps prevent medical bills from becoming unaffordable. The other ideas describe a fixed fee per visit (a copay), the portion of costs after the deductible (coinsurance), or the total premium, none of which describe the cap on yearly spend.