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.
The out-of-pocket limit is the maximum amount of covered expenses the patient and the patient's family could pay each year. After the patient has met the annual deductible, he/she generally pays a percentage of covered expenses (often 20 percent), up to the patient's out-of-pocket limit. Once the patient has reached his/her out-of-pocket limit, the plan pays 100 percent of covered expenses for the remainder of the calendar year.
See Out-of-pocket maximum.
An amount specified in a health care plan that is the maximum amount of out-of-pocket expenses for which the covered individual is responsible. After the maximum is reached, the insurer pays for the covered charges in full, up to the coverage maximum, if any. Such health plan provisions are, in effect, limits on cost-sharing.
The maximum coinsurance an individual will be required to pay, after which the insurer will pay 100% of covered expenses up to the policy limit.
The out-of-pocket limit is the maximum amount of covered expenses that you must pay in a calendar year. Once you have met your out-of-pocket limit, the plan pays 100 percent of covered reasonable and customary medical expenses. Close Window
The dollar amount that an employee is responsible for paying for medical care during a certain period of time, usually a calendar year. The insurer pays 100% once the out-of-pocket limit has been reached.
A cap placed on your out-of-pocket costs, after which benefits increase to provide full coverage for the rest of the year. It is a stated dollar amount set by your insurer, in addition to regular premiums.
The maximum coinsurance an individual is required to pay, after which an insurer will pay 100% of any covered expenses up to the policy limit.