What is an out-of-pocket maximum?

What is an out-of-pocket maximum? Posted On
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What is an out-of-pocket maximum?

An out-of-pocket maximum is the most you will pay each year for covered health care.

Learn more about your out-of-pocket maximum and how to control it below. To find out how the out-of-pocket maximum works with other health care costs, see Paying for health care.

How does the out-of-pocket maximum work?

The maximum out-of-pocket expense is the most you could pay for covered medical services and/or prescription drugs per year. The out-of-pocket maximum does not include your monthly premiums. It usually includes your deductible,  coinsurance, and copays, but this can vary by plan.

If you need medical care for a chronic illness, an expensive drug, or surgery, you could reach your out-of-pocket maximum.

How do I control what I have paid?

Here’s an example of how out-of-pocket maximums work:

Jenny is due for surgery and wants to make sure she receives the maximum level of coverage. Before surgery, she checks to make sure her doctor and hospital de Ella are in her plan’s network * and follows the steps required for prior authorizations.

  • The total cost of Jenny’s surgery is $10,000 after the plan processes the claim.
  • You have a $1,500 deductible with 20% coinsurance and a maximum out-of-pocket expense of $3,500.

Jenny pays her doctor and hospital $3,200 ($1,500 deductible plus $1,700 coinsurance). She has $300 more to pay before she reaches her out-of-pocket maximum.

If Jenny had gone out of her plan’s network for the surgery, she would have had to meet a higher out-of-pocket maximum. Her deductible could also be higher than for in-network care. For this reason, it is important to seek care in her plan’s network, because she will have lower out-of-pocket costs. Jenny would have to pay all the costs that Blue Cross doesn’t cover if she received care outside of her plan’s network. These costs will not count against her in-network out-of-pocket maximum.

What happens when I reach my out-of-pocket maximum?

When you reach your in-network out-of-pocket maximum, your health plan pays for covered health care and prescription drugs for the rest of the year. Your plan will pay these costs only if the services and prescription drugs are medically necessary.

More information about health care costs

This is general information about how plan benefits work. Review the Summary of Benefits and Coverage and benefit booklet for your specific health plan for information about how your plan works.

It is up to you to always verify if your provider is in your health plan’s network before receiving services. Not all providers are in all networks. You may pay more or all of your health care costs if your provider is out-of-network or does not have a contract with Blue Cross (this is called a non-participating provider). You can check if your provider is in your network by calling customer service at the number on the back of your member ID card.

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