Definition Out of Pocket Maximum OOP


The Out of Pocket Maximum OOP is the most you have to pay for covered services in a plan year, even if your claims total $1 million or more!

You reach your  OOP Maximum  once you’ve paid out that amount on 

Then your health plan pays 100% of the costs of covered benefits.

Or to say it another way,

OOP Refers to the maximum amount that an enrollee will have to pay for expenses covered under the health plan. The maximum is a sum of all paid deductible and co-payment or coinsurance amounts.out-of-pocket maximum. This means that once your expenses reach a certain amount in a given calendar year, the reasonable and customary fee for covered benefits will be paid in full by the insurer.   Specimen Policy Page 5      56   

The out-of-pocket limit doesn’t include your monthly premiums. It also doesn’t include anything you may spend for services your plan doesn’t cover.

The law (ACA/Obamacare Covered CA) sets  maximum out-of-pocket limits based on your  Metal Level Bronze, Silver, Gold & Platinum.  AB 1305, 339 & 1954  SB 999 – Deductible & OOP Maximums * Blue Shield How Plan Works Negotiated Rate, Deductible, Co Pay, Coinsurance OOPFAQ’s

United Health Care Webpage explaining Payment on Out of Network Benefits for certain plans.


Example of out-of-pocket maximum with high medical costs

Let’s say you need surgery with allowable costs of $20,000, and the following figures apply to your health insurance plan.

You pay the first $1,300 of covered medical expenses (your deductible).

Your 20% coinsurance on the rest of the costs ($18,700) comes to $3,740.

So your total costs would be $5,040. That’s $1,300 (your deductible) plus $3,740 (coinsurance).

But your out-of-pocket maximum is $4,400. Your insurance company pays all covered costs above $4,400 — for this surgery and any covered care you get for the rest of the plan year.

Generally, plans with lower monthly premiums have higher out-of-pocket limits. Plans with higher premiums usually have lower out-of-pocket maximums. HealthCare.Gov




is a type of member cost sharing that requires a flat amount per unit of service or unit of time. This is may be a percentage of the charges or a dollar amount for specified services.  See also Blue Cross Specimen Policy Page 161

Co Pay example
Co Pay example

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The deductible is the amount the insured person must pay for covered services during a calendar year, January 1 through December 31, before health benefit payments begin. The deductible is usually a set amount or a percentage determined by the member’s contract – insurance policy. For example, a plan might require the insured to pay the first $500 of covered expenses during a calendar year before any benefits are payable.

Learn about Embedded vs aggregate deductible

How deductible works as explained in Sampe EOC page 54  Definition 

How might an HSA Health Savings Account help you save up to pay the deductible?

News reports about how high deductibles leave people effectively without medical care as people are living on the edge – paycheck to paycheck.

Los Angeles Times May 2, 2019 * May 2 3 Kids $15k Medical Debt  *  

NPR May 3, 2019

New York 5.3.2019 

North County Public Radio  5.3.2019

Deductible #Carryover.

Many plans used to offer a provision called a deductible carryover.  However, Last quarter deductible carry over has gone by way of the dinosaurs – carriers no longer offer this.

This provision allows you to carry over to the next year any unmet portion of the deductible that you, or your family, run up in October, November and December. For example, assume you had no medical claims in the first part of the year. In November, you run up $350 worth of claims. If your deductible was $500, you would start the next year with $350 of your $500 deductible already meet.  Example

However, there is deductible credit for PPO plans  since all plans are set up for Calendar Year and a renewal won’t effect this nor  a carrier change in the middle of the year since deductible credit for the yearly medical deductible is given by the new carrier (client has to submit EOBs)  9.11.2015 email from Heide Definition – Investopedia LISA Broker Wholesaler – How and what you need to do to get credit when moving from one insurance company to the other.

Benefit Period

The length of time we will cover benefits for Covered Services. For Calendar Year plans, the Benefit Period starts on January 1st and ends on December 31st. For Plan Year plans, the Benefit Period starts on your Group’s effective or renewal date and lasts for 12 months. (See your Group for details.) The “Schedule of Benefits” shows if your Plan’s Benefit Period is a Calendar Year or a Plan Year. If your coverage ends before the end of the year, then your Benefit Period also ends.  EOC   

Crediting Prior Plan Coverage

If you were covered by the Group’s prior carrier / plan immediately before the Group signs up with us, with no break in coverage, then you will get credit for any accrued Deductible, if applicable and approved by us, under that other plan. This does not apply to people who were not covered by the prior carrier or plan on the day before the Group’s coverage with us began, or to people who join the Group later. If your Group moves from one of our plans to another (for example, changes its coverage from HMO to PPO), and you were covered by the other product immediately before enrolling in this product with no break in coverage, then you may get credit for any accrued Deductible, if applicable and approved by us. If your Group offers more than one of our products, and you change from one product to another with no break in coverage, you will get credit for any accrued Deductible, if applicable. This Section Does Not Apply To You If:

· Your Group moves to this Plan at the beginning of a Benefit Period; · You change from one of our individual policies to a group plan; · You change employers; or · You are a new Member of the Group who joins the Group after the Group’s initial enrollment with us.

How Premiums and Deductibles Work

how premiums & deductibles work video

Deductible Carry Over
Deductible Carry Over

Kaiser Group Explanation 


A way in which the enrollee shares in the cost of health care. The benefit plan requires the enrollee to pay a flat dollar amount per unit of service. An example of a common co-pay is $10 per physician office visit.

An arrangement under which the insured person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, a health plan might pay 80% of the allowable charge, with the enrollee responsible for the remaining 20%; the 20% amount is then referred to as the coinsurance amount.




Understanding Health Insurance Costs

Understnading Health Insurance Costs

It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc!  Plus, EOC's are mandated to be written in PLAIN ENGLISH!

Specimen Policy #EOC with Definitions
Specimen Policy with Definitions

Steve Explains how to read EOC

Reasonable and customary amount

“the usual, customary, and reasonable amount,” and “the prevailing rate” are among the standards that various health care benefit plans may use to pay out-of-network benefits.

Please scroll down for more details and explanations of each of the key terms as they are interrelated.

Comments FAQ’s
Ask Us a Question

Can you explain a couple basic things  about my Blue Shield of California, Bronze, HSA plan (non-exchange), for ONE person in the 91941 zip code?

***First, let’s refer to the Actual (EOC) – Evidence of Coverage by clicking here.  The EOC on page 3 refers to the “matrix summarizing key elements” to verify the actual numbers.  I believe the matrix is the benefit summary guide (where it does say in the body, that it is the Uniform Plan Benefits and Coverage Matrix  and for the PPO HSA Bronze that is on page 55.

I’ve called Blue Shield three times but have yet to get a native speaker that can explain this to me.  It’s complicated (to me)– so I want to make sure I understand properly.  Their web site is horrible – so I thought I’d ask you.  I figured you’d know the answer off the top of your head.

***I might have it off the top of my head, but I like to have an actual citation, so that I don’t have to pay a claim if I’m wrong.

My plan is as follows:

HSA Bronze Participating Providers Non-Participating Providers
Calendar Year Deductible $4500 $4500
OOP Max $6250 $9250
Co-pay 40% 50%

 ***I like to take a screen shot of the actual Insurance Company Brochure

Actual Screen Shot of Benefits Matrix
Actual Screen Shot of Benefits Matrix

Questions for you are:

  • Does my $4500 deductible apply/accrue to the $6250 max OOP, in network?  In other words,
    1. Once I pay out $4500 in deductible payments, then I have another $1750, in co-pays (at 40%) to pay out… at which point I will have reached the maximum out of pocket for the year


Out of Pocket Max includes deductible and applies to participating and non participating MD's
Out of Pocket Max includes deductible and applies to participating and non participating MD’s


  1. After I have paid out all the deductible ($4500), then the co-pay counter starts at zero (at  40%) and I have an additional $6250 to pay out (effectively making my “annual OOP” $10,750? )
  • What happens when some of my provides are “not-participating” providers.  I have some labs and such that aren’t part of “the network”  for lab work that was “subbed out”.
    1. Does the same $4500 deductible apply to non-participating providers AND  participating providers – or – does my deductible start at $zero with a new $4500 deductible for non-participating providers as well (thereby making the deductible $9000 for in and out of network?

***This is why I like to view the ACTUAL EOC or Summary of benefits

Deductible applies to both participating and non participating Providers
Deductible applies to both participating and non participating Providers
    1. What about the OOP max?  Does is the $9250 inclusive or exclusive of the $6250 max OOP for “non-participating” providers?

***Inclusive is a big word for me.  See above, co-pays apply to both participating and non participating facilities.

  • How do I best deal with my ‘in-network” providers sending my stuff (labs, etc) out to non-participating providers without my knowledge?   Just suck it up or what?

***Ask them to do their best to send you to net work providers, they are supposed to do that automatically.  Learn More on page 9 – choice of providers…  in the EOC.  The EOC states that Blue Shield will consider a request for services that cannot be reasonably provided in the network.

Here’s a couple of questions from our clients posted for it’s educational value.

I can’t believe how high the deductibles are!  So if the deductible is $6000,

***Do you mean deductible or out of pocket maximum?

we have to pay for all doctor visits and tests, ex-ray, etc. until we have paid $6000 before insurance kicks in?

***Many benefits like preventative and many doctor visits are not subject to the deductible – read the summary of benefits, click details on our quote engine.

Blog Insure Me 11.26.2016 practical limitations money wise of going out of network – namely Maximum Out of Pocket OOP Limit is effectively much higher.

I think I know the answers – but each of the BS people told me a different story (at least I think they did – I couldn’t understand them).. Yikes!

***I Thank you VERY much for sending the question which you wrote out very well in writting and allowing me the time to find the actual  Plan Benefits & Coverage Matrix.

Insurance #definitions & glossary

The best place to look for Insurance definitions & glossary  is in an actual EOC – Evidence of Coverage  (specimen – Platinum) – Policy. Be sure to check your ACTUAL EOC for your specific question.

See our definitions, video’s, guides, etc. below and on the sides.

Numerous other Medical, Legal & Insurance Dictionaries

CA Dept of Insurance Glossary

CMS – Medicare

Medicare Part D Rx Guide Definitions # 11109

AB 1083 Definitions – Small Employer Health Care Reform Legal Dictionary Lectlaw Medicare Glossary

Health Net 6  page glossary

 Español (Spanish)

Court Site

Legal Dictionary Lectlaw

Medi-Cal – Helpful words to know

Department of Labor – Health Benefits Advisor   ***   Glossary

Texas DOI Glossary

Glossary of Employee Benefit Terms

State of CA Insurance Dept.

CA DOI – Health Insurance Terms

Glossary – Annuity Advisors LOMA

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Our Webpage on Insurance Coverage for 


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16 comments on “OOP -Out of Pocket Maximum – Participating or Not? Deductibles & Co- Pays


    In 2022, the most consumers with an individual plan will have to contribute to their health care costs will be $8,700, with the limit set at $17,400 for coverage for more than one person.

    The maximum limits will be less for people with lower incomes. For ACA plan participants whose income is between 100 percent and 200 percent of the federal poverty level (between $12,880 and $25,760 in 2021), the maximum they will have to pay out of pocket in 2022 will be $2,900 for individual coverage and $5,800 for coverage of more than one person. And for those whose incomes are between 200 percent and 250 percent of the poverty level (between $25,760 and $32,200 in 2021), their maximum out-of-pocket limits will be $6,950 for self-only coverage and $13,900 for coverage of more than one person.

  2. her plan required a 30% coinsurance payment on operations, pressed the person on the phone several times to make sure she had heard correctly:

    Her coinsurance payment would be only 20% if she had the procedure at Palomar Medical Center in Poway, California, about 38 miles south of where Qiu lives.

    “I was kind of in doubt, so I called them a second time,” said Qiu. “They gave me the exact same amount.”

    Read more

  3. Is the $2,500 deductible 100% out of pocket before any insurance benefits kick in, or do I have co-pays while meeting the $2,500 deductible?

  4. I’m considering between Sharp Bronze HSA and Kaiser Bronze HMO plans.

    It is clear I would pay $75 doctor’s visit before deductible with Kaiser’s plan but with Sharp, it says 40%.

    Does it mean before deductible of $4,800 is met?

  5. Thanks for the clarification Steve. You’re an amazing agent – one who actually works for me all year round.

    • Got it – thanks Steve…

      If I understand this correctly –

      For in network providers my “max OOP” is:

      $4500 deductible
      +$1750 of co-pays at 40%

      $6250 total OOP

      For out of network
      Same $6250 from above
      + $3000 of additional co-pays to reach
      $9250 total OOP for in and out of network providers

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