Out-of-Pocket Maximum
The legal upper limit on what you must spend on covered in-network medical care in a single policy year.
Actuarial & Contractual Mechanics
The out-of-pocket maximum is your ultimate financial backstop in health insurance. Once your cumulative deductibles, copays, and coinsurance reach this statutory ceiling in a calendar year, the insurance company pays 100% of all remaining covered medical expenses. Simulate your annual exposure on our Out-of-Pocket Cost Calculator and read our US Health Insurance Guide.
Liam faces major cancer treatments totaling $250,000. Liam's plan has a $7,500 out-of-pocket maximum. Liam pays $7,500, and the insurer covers the remaining $242,500.
Non-covered treatments, out-of-network balance billing, and unapproved medications do NOT count toward this limit. Learn how to appeal denied charges in What Happens If a Health Insurance Claim is Denied?.
Frequently Asked Questions About Out-of-Pocket Maximum
Clear definitions, policy implications, and related coverage calculators.