Definition
The most you will pay for covered in-network health care in a plan year; after that, the plan pays 100% of covered costs.
What it means
The out-of-pocket maximum, or limit, caps what you spend on deductibles, copayments and coinsurance for covered, in-network services during a plan year. Once you reach it, the health plan pays the full cost of covered benefits for the rest of the year. Premiums, out-of-network care and services the plan does not cover do not count toward the limit. Under the Affordable Care Act, most plans must have an out-of-pocket limit no higher than a yearly federal maximum, which is updated each year; many plans set lower limits. Family plans have a family limit and an individual limit within it. Knowing the maximum helps estimate the worst-case cost of a serious illness or injury in one year. Original Medicare does not have an out-of-pocket maximum, although Medicare Advantage plans do.
Example
With a $6,000 out-of-pocket maximum, someone facing $80,000 in covered in-network hospital bills in one year pays at most $6,000 plus monthly premiums.
Illustrative numbers only. Your situation will differ.