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Health insurance & HSAs
The out-of-pocket maximum is the most an enrollee pays for covered in-network care in a plan year through deductibles, copays and coinsurance. After it is reached, the plan pays 100% of covered services for the rest of the year. Premiums do not count toward it, and out-of-network care may not either.
The out-of-pocket maximum is the worst-case number, and it is the figure prospects most often skip when comparing plans by premium alone. For a family expecting a surgery or a birth, it is usually the number that decides the choice.
The HSA versus traditional plan calculator explains the term in its definitions and models net cost from premiums, deductibles and expected costs. A Medicare Advantage plan has its own annual in-network limit set by CMS, which is a different rule from the one that applies to employer and individual plans.
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