What Is an Out-of-pocket Maximum?

What Is an Out-of-pocket Maximum?

What Is an Out-of-pocket Maximum?

We know health care terms can be confusing. One you’re sure to run across is “out-of-pocket maximum.” What does it mean? How does it affect you and your family? How does it influence your choice of health plan?

You share the cost of your care with your health insurance company. You pay money to cover your deductible, coinsurance and copays. But here’s some good news: There is a limit to how much you are required to pay. It’s called your out-of-pocket maximum (OOPM). And it is the most you’ll have to pay during a policy period – usually a year – for health care services.

If you are a current BCBSIL member, you can see your plan’s OOPM in Blue Access for MembersSM. It’s different for every type of plan. Here are some things to keep in mind:

  • Your OOPM limits how much you can be charged for your health care expenses. This limit protects you if serious and expensive medical issues come up.
  • The government can change the OOPM each year. For 2022, the highest OOPM a plan can have is $8,700 for an individual and $17,400 for families. If you selected a Blue Advantage Bronze HMO Plan or Blue Advantage Plus Bronze HMO Plan, your OOPM will be $7,000 per individual. With a Blue Advantage Gold HMO Plan, your OOPM will be even lower.
  • Remember, if you go out of your network for services, those expenses may not count toward your OOPM, and you could have to pay more.

Take this scenario for example:
Joe’s plan has a $8,700 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 $8,700 for covered expenses this year, even if his care costs more.

Read more about a deductible vs out of pocket maximum.

Before you even choose a health insurance plan, it’s important to first consider your plan’s doctor network. Our Provider Finder® tool will help you know 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!

Originally published 2/24/2015; Revised 2022

  • 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