Insurance 101: Plain-English Library

What is an Out-of-Pocket Maximum?

If there is only one number you look at when buying health insurance, make it the Out-of-Pocket Maximum (OOPM).

The Worst-Case Scenario Cap

This number is literally the absolute maximum amount of your own money you will have to spend on covered healthcare in a single calendar year. If you get into a terrible accident and rack up a $1,000,000 hospital bill, but your Out-of-Pocket Maximum is $8,000... you only pay $8,000. Your insurance legally has to cover the remaining $992,000.

What counts towards it?

Your deductible, your copays, and your coinsurance all count toward this limit. However, your monthly premium does not count. Once you hit this magical limit, covered medical care is 100% free for the rest of the year.

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