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The out-of-pocket maximum, also called OOPM, is the most you will have to pay out of your own pocket for expenses under your health insurance plan during the year. If you are a current BCBSTX member, you can see what your plan’s OOPM is within Blue Access for Members. The OOPM is different for every type of plan.
Here’s how it works:Joe’s plan has a $6,000 out-of-pocket maximum. That is the most Joe will pay this year out of his own pocket for covered medical expenses. Joe only pays for the medical care he uses. If he’s healthy, he may only pay for a few doctor visits and prescriptions, but if he has an accident or major illness, that accident or illness could mean costly hospital bills. However, because Joe has health insurance and stays in network, he won’t have to pay more than $6,000 for covered expenses, even if his care costs more.Here’s how it works:Example:
Joe’s coinsurance responsibility after the service is $10,000-($250+$2,000)=
Since his cost is over his OOPM and he is in network, Joe is only required to pay his up to his OOPM, $6,000. Read more about a deductible vs out of pocket maximum.
As you can see, it’s important to consider your plan’s doctor network and your responsibilities when choosing a health insurance plan. To see if your doctor and hospital of choice are in a plan’s network, use our Provider Finder tool.
Still have questions about your out of pocket maximum? Ask below!
I have met my oopm this year and I have an Echo scheduled. The Dr. is in network and told me that my copay would be $45. That $45 comes out of my pocket, so should I have to pay this copay? Thank you
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