What doesn’t count towards the out-of-pocket maximum?

Your monthly premiums and anything the plan doesn’t cover. Out-of-network care may not count either. Your plan documents say exactly what counts.

Is the out-of-pocket maximum the same as the deductible?

No. The deductible is what you pay before the plan starts sharing costs. The out-of-pocket maximum is the cap on your total share, deductible included.

Does the out-of-pocket maximum reset?

Yes, at the start of each plan year.

OUT-OF-POCKET MAXIMUM

What is an out-of-pocket maximum, and how do I track it?

Your out-of-pocket maximum is the most you have to pay for covered services in a plan year. Once your deductibles, copays and coinsurance for in-network care reach it, your plan pays 100% of covered benefits for the rest of that year.

Why it’s confusing

It is a safety cap, but it only counts certain spending. Premiums don’t count, care the plan doesn’t cover doesn’t count, and out-of-network spending may not count — so people add up everything they spent and are surprised the cap hasn’t been reached.

Family plans can have both an individual and a family limit, and the figure resets at the start of each plan year.

How to read it

Your EOBs show how much of each claim went to your deductible, copay and coinsurance. Many EOBs also show a running “year to date” total against your deductible and out-of-pocket maximum — often near the top or the end.

If yours doesn’t, your insurer’s app or member portal usually does. Compare that running total with the maximum in your plan’s summary of benefits.

When a claim arrives after you have reached the maximum, the EOB should show the plan paying the full allowed amount for covered in-network care, with nothing left for you.

What it does not mean

That nothing else can be billed once you reach it. Non-covered services and some out-of-network charges sit outside the cap.
That monthly premiums count towards it. They don’t.
That it carries over. It resets each plan year.

Where you’ll see it

Year-to-date summaries on insurance EOBs.
Your plan’s summary of benefits and coverage.
The “benefits” or “spending” page of an insurer’s app or portal.

Questions worth asking

Ask your insurer

How much have I paid towards my out-of-pocket maximum this year?
Is there a separate family limit on my plan?
Will this service count towards my out-of-pocket maximum?

Want to know what your EOB says about your yearly totals? Attach it, and Clariti will explain.

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Common questions

What doesn’t count towards the out-of-pocket maximum?: Your monthly premiums and anything the plan doesn’t cover. Out-of-network care may not count either. Your plan documents say exactly what counts.
Is the out-of-pocket maximum the same as the deductible?: No. The deductible is what you pay before the plan starts sharing costs. The out-of-pocket maximum is the cap on your total share, deductible included.
Does the out-of-pocket maximum reset?: Yes, at the start of each plan year.