WHAT IF YOU HAVE REACHED YOUR MAXIMUM BENEFIT LIMIT?

Out-of-pocket maximum refers to the maximum amount of money you have to pay for covered medical services in a plan year. Once you have reached that limit, your health plan covers all costs for covered medical expenses for the rest of the plan year. However, a plan year is the 12 months between the coverage start and ends.

The amount of your out-of-pocket maximum will vary depending on the plan. If you have dependents on your healthcare plan, have a separate out-of-pocket maximum for families and individuals.

How does it work?

• Let’s assume Smith A. has a health care plan with 20% coinsurance, a $2500 deductible, and a $4000 out-of-pocket maximum plan.
• Due to an emergency, he sees the doctor & specialists regularly and leads to medical tests. • He receives the bill of $2500 and pays these costs through cost-sharing deductibles. • The treatment requires further tests and visits, and now he pays through 20% coinsurance as his share of costs that is $1500, and the plan pays another 80%.
• At this stage, Smith has spent $4000 and has reached the maximum benefit limit. • Once you have reached that limit, the health plan will pay 100% of all covered medical expenses for the rest of the year.

Types of cost-sharing expenses in out-of-pocket maximum

The price you pay for covered medical services is the out-of-pocket maximum that includes deductibles, copayments, and coinsurances.

• Deductibles: Your deductible is the cost you pay first for in-network care before the insurance kicks in and covers all costs for preventive care. Check with your plan details if the deductible goes towards the out-of-pocket max.
• Coinsurance: The percentage amount your health plan shares with you once you meet the deductible. Your share here counts towards an out-of-pocket maximum.
• Copayments: This is a flat rate you have to pay usually at the time of the service.

The expenses that don’t count as out-of-pocket maximum

Even with health coverage, not all cost-sharing goes towards your annual limit. Therefore, it is crucial to know which do not.

• Premiums: If you buy a healthcare plan on your own, you keep paying the premiums even once you meet the limit.
• Non-covered services: Health services won’t count towards the maximum limit, such as weight loss surgery, cosmetic treatment, and a few alternative medicines.
• Out-of-network services: Most plans require you to use network providers due to discounted rates. If you choose out-of-network care, then it does not count towards the out-of-pocket maximum. Make sure to check the network provider’s details before seeing them.
• Preventive care: Most healthcare plans cover 100% of the preventive care costs such as flu shots, some lab tests, routine check-ups, routine screenings, and vaccinations, as part of ACA. All healthcare plans that meet the standards of ACA have out-of-pocket maximums. Make sure to check the details.

Not everyone meets their out-of-pocket maximum, as it varies and depends upon your specific needs. If you are healthy and visit the doctor just for a routine check-up, it gets paid under preventive care. You would have few costs and do not even meet the deductible.