The Out of Pocket Maximum is the most you have to pay for covered services in a plan year.  After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.

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 sets  maximum out-of-pocket limits based on your  Metal Level Bronze, Silver, Gold & Platinum.  AB 1305, 339 & 1954  SB 999 – Deductible & OOP Maximums FAQ’s

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


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

May 2019 Articles

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  

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

How Premiums and Deductibles Work


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.



Out-of-pocket maximum
Coinsurance maximum OOP – Out of Pocket

refers to the most you pay for covered expenses during the year before your plan begins paying 100% of covered expenses for the remainder of the year. It is a sum of deductible and coinsurance amounts. Only covered expenses, as determined by your contract, count toward the maximum. Other costs, such as amounts you pay for non-covered services or charges in excess of our allowances, don’t count.

This is the maximum dollar amount of Covered Expenses for which the Member is responsible in a Calendar Year. After that maximum is reached, this plan will pay 100% of Covered Expenses incurred during the remainder of that Calendar Year.

Out-of-pocket (OOP) maximum mandate
All cost sharing must apply toward the OOP maximum,including in-network medical, behavioral health and pharmacy cost-sharing. This does not include premiums,balance billing amounts of non-network providers or spending for non-covered services.
The out-of-pocket maximum must include:
•  Copays
•  Deductibles
• Coinsurance

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



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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


Understanding Health Insurance Costs

Understnading Health Insurance Costs

Example of how claim is paid under different metal levels
Cost Scenario Heart Disease - by metal level - Click to enlarge *  View more Examples 

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.

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

  1. 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?

  2. 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?

  3. 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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