What is an out-of-pocket maximum?

An insurance plan's Out-of-Pocket (OOP) maximum is how much someone will have to spend on healthcare before the insurance carrier will cover 100% of their medical expenses.

For example, if an employee selects a plan with a $5,000 OOP max and spends $5,000 out of pocket by mid-year, any medical costs that are incurred for the rest of the plan year will be 100% covered by their insurance company.

The OOP maximum does not carry over from plan year to plan year -- it resets with the plan year, much like deductibles.

Employees can view their plan's OOP maximum from the Medical Overview page under the Benefits Summary section.

The amount applied to the OOP maximum may vary depending on whether medical expenses were incurred inside or outside of the plan's network.

Was this answer helpful?  

Still need our help? Our support team is waiting to help you. Contact us