Maximum Out of Pocket – What’s that?


What does “Maximum out of Pocket” mean?

This is a good question that we discuss frequently.  In general, as consumers, we are pretty conditioned to think that there’s always a ‘loophole’ or a ‘catch’ and that there must be exceptions.  Fortunately, with this particular feature of an Affordable Care Act compliant health insurance policy, the answer is straightforward.

Maximum out of Pocket = deductible + coinsurance + service co-pays + prescriptions

Premiums are excluded from the Maximum out of Pocket.  Once the Maximum out of Pocket has been met for  the plan year, care is covered at 100% for the remainder of the plan year.  Please note, this only applies to care that is included in the policy.  If you have met your Maximum out of Pocket and then get cosmetic surgery, which is excluded from your policy, the fact that you have met your Maximum out of Pocket is immaterial – you still have to pay 100% for excluded services.

At Webb Insurance we are passionate about finding great solutions for our clients.  If you’d like to talk more please contact us at 800.303.6329 or here.

Webb Insurance provides advice and guidance for the purchase of health insurance.  We do not provide tax or legal advice, we never said we did that and we aren’t starting now.  Always consult a qualified tax or legal professional for that sort of thing.