Out-of-pocket maximum and your bottom line

out-of-pocket maximum Wednesday, November 08, 2017

When it comes to your out-of-pocket maximum (OOPM), reaching your limit can be a good thing. An out-of-pocket maximum is the most you pay toward the cost of your healthcare in a year, excluding your monthly health plan bill and a few other key exceptions.

Your deductible, copays, and coinsurance all count toward your out-of-pocket maximum if you visit in-network doctors. Once you've reached that amount, your health plan pays for the rest of your healthcare that year. The out-of-pocket maximum is designed to limit your financial risk when you're dealing with a chronic or serious healthcare issue.

The Affordable Care Act (ACA) set a limit on the maximum out-of-pocket cost for individual or group health plans. The limit is $7,350 for individuals and $14,700 for families in 2018. Your out-of-pocket maximum may vary depending on the plan you choose. Gold plans generally have the lowest and bronze plans have the highest.

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What counts?

  • Your annual deductible
  • Coinsurance and copayments for doctor visits and other medical treatment
  • Prescription drugs

What doesn't count?

  • Your monthly bill (premium)
  • Your share of bills from non-network providers
  • Spending for treatments that are not eligible for coverage by your plan
  • Payments for adult vision or adult dental care

Hit your limit?

You can find out how much you've spent toward your out-of-pocket maximum on premera.com or our mobile app. To find the maximum for your plan, log in, and under Member Services, click Benefit Plans. Then click Deductibles and Maximums to find your plan information. Questions? Call customer service at the number on the back of your ID card.

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