Out-of-Pocket Maximum

From SmartMedicalConsumer Wiki

The maximum dollar amount, including deductibles and coinsurence that you pay in any calendar year toward the cost of covered medical care. Once you reach your individual or family out-of-pocket maximum, the health plan will cover your eligible services at 100% for the remainder of the calendar year.

Most insurance policies that have co-pays do not count copays as part of the deductible or as part of the out-of-pocket payments towards out-of-pocket maximum.

Once the out-of-pocket maximum is reached, the health plan covers 100% of the allowable amount (covered portion) of a service. Thus, if your provider bills you for more than the allowed amount, you may need to pay the difference.

For example, your doctor bills you for $200; you already reached your out-of-pocket maximum; and your insurance allows only $120 out of $200. If this provider is not a participating provider or an in-network provider, you will pay the remaining $80. Although you end up paying this amount, this difference is not counted towards your out-of-pocket payments.