What is an out-of-pocket maximum?

We know health care terms can get confusing. One of them is “out-of-pocket maximum”. What does it mean? How does it affect you and your family? How does it affect choosing a health plan?

We’ve answered these questions and more!

The out-of-pocket maximum, also called OOPM, is the most you will have to pay out of your own pocket for expenses under your health insurance plan during the year. If you are a current BCBSIL member, you can see what your plan’s OOPM is within Blue Access for Members. The OOPM is different for every type of plan.

  • Your health Insurance plan may require you to pay for some expenses out of your own pocket when you need care
  • The OOPM limits how much you can be charged for these expenses — protecting you in case of serious and expensive medical problems
  • The government can change this each year, and the maximum OOP cannot go over this amount. For 2015, the highest OOPM a plan can have is $6,600 for individuals and $13,200 for families. If you selected a bronze plan, your OOPM will be closer to $6,000 per individual, and if you purchased a gold or platinum plan, your OOPM will be lower than that.
  • If you go out of your network for services, those expenses may not count toward your OOPM, so you could have to pay more.


Take this scenario for example:
Joe’s plan has a $6,000 out-of-pocket maximum. That is the most Joe will pay this year out of his own pocket for covered medical expenses. Joe only pays for the medical care he uses. If he’s healthy, he may only pay for a few doctor visits and prescriptions, but if he has an accident or major illness, that accident or illness could mean costly hospital bills. However, because Joe has health insurance and stays in network, he won’t have to pay more than $6,000 for covered expenses this year, even if his care costs more.
Here’s how it works:

Example 1:

Cost of an in network service: $10,000
Joe’s copay :       $250
Joe’s coinsurance : 20% or $2,000
Joe’s OOPM   $6,000

Joe’s coinsurance responsibility after
the service is $10,000-($250+$2,000) =    

$7,750


Since his cost is over his OOPM and he is in network, Joe is only required to pay up to his OOPM, $6,000. Read more about a deductible vs out of pocket maximum.

Before you even choose a health insurance plan, it’s extremely important to first consider your plan’s doctor network and your responsibilities. Our Provider Finder tool can help you check if your doctor and hospital of choice are in a plan’s network .

It’s a lot to digest, so if you still have a few questions about your out of pocket maximum, ask us in the comments!

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Anonymous
  • I noticed a typo in my example above.  In the first paragraph, he would be left with $3750 on his out-of-pocket limit for the year (not $3250).

  • I don't understand this example.  If Joe's copay is $250 and his co-insurance is $2000 (20% of the cost of service), then why does the example say his cost is $7750?  It seems like his out-of-pocket costs for this service are then $2250, which leaves him with $3250 left on his out-of-pocket limit for the year (assuming he has spent nothing else so far this year)?

    This example doesn't mention anything about his deductible, though, either.  I thought co-insurance only applies after the deductible is satisfied?  So if Joe has a $3000 deductible, his costs are then $250 for his copay plus $3000 towards his deductible.  Then his co-insurance takes effect.  I'm not sure how that works in this case since he has paid $3000 of the $10000 cost already.  Does the co-insurance apply to the remaining $7000?  So his additional cost is 20% of $7000 ($1400)?  Or does the co-insurance still apply to the total cost?  So his additional cost is 20% of $10000 ($2000)?  In the latter case, Joe is then responsible for his $250 copay + $3000 deductible + $2000 coinsurance, for a total of $5250, leaving him with $750 remaining towards his OOPM for the year.

    Can someone clarify this for me?  Thanks.

  • Hi George21546, It may be that there is something, such as a copay amount, that applies to your out of pocket amount but not your deductible and this could make it so you meet the out of pocket first. We're happy to check on this for you to see what's going on. If you'd like us to check this you can send us a private message with your plan ID and contact information. ~ Kayla

  • If my deductible is $1500 and my max out of pocket is also $1500 than why is it that I've reached over the oopm and still not yet reached the deductible?