Definitions for "Out-of-pocket limit"
Maximum amount established by a health plan that an individual member or his or her family will have to pay toward their medical care in a given year in deductible coinsurance and co-payments. Once this limit is met, the plan will pay 100 percent of the costs of future covered health services until the new policy year begins. However, health plans may exclude certain costs from the out-of-pocket maximum. For example, you may not be able to count the costs of non- covered services, or any costs incurred by failing to follow the health plan’s prior approval process.
Your out-of-pocket maximum is designed to protect you against high medical expenses, and includes any deductibles and/or co-insurance that you have paid during the year. Once your out-of-pocket limit has been reached, you are not responsible for paying additional amounts for services received. Note that out-of-pocket limits only pertain to covered services and amounts within the usual and customary limits.
The total payments toward eligible expenses that a covered person is responsible for. This includes deductibles, copays, and coinsurance as defined in the contract. Once the limit is reached, benefits increase to 100 percent for health services received by the covered person during the remainder of that calendar year.