Understanding your out-of-pocket maximum vs. deductible

When you meet your deductible for the year in qualifying medical services and expenses, you’ll then pay a set copay or coinsurance (a percentage of the provider’s charge for your medical needs) until you reach the out-of-pocket maximum.

What are out-of-pocket maximums??

Your out-of-pocket maximum or limit is the most you will ever have to pay out of your own pocket for annual health care. This limit includes the deductible, copays, and coinsurance you will continue to pay after you reach the deductible. When this maximum is met, any dollar over that amount will be 100% covered by your insurance provider. However, your monthly premium, out-of-network services, and services not covered by your plan are not included in the out-of-pocket maximum.

The out-of-pocket maximum for Affordable Care Act plans can vary, but they are not allowed to go over a set amount each year. In 2020, that amount was $8,150 for individual plans and $16,300 for family plans. In 2021, those amounts have increased to $8,550 for individuals and $17,100 for families.

Typically, the out-of-pocket maximum is higher than your deductible amount to account for the collective costs of all types of out-of-pocket expenses such as deductibles, coinsurance, and copayments.

The type of plan you purchase can determine the amount of out-of-pocket maximum vs. deductible costs you will incur. HealthMarkets can help you find the right health plan for your budget and medical needs. Just visit us online to start comparing plans today.