Insurance Basics: Out-of-Pocket Maximum

We know health care terms can be confusing. One you’re sure to run across is “out-of-pocket maximum.” What does it mean? How does it affect you and your family? How does it influence your choice of health plan?

You share the cost of your care with your health insurance company. You pay money to cover your deductible, copays and coinsurance (if coinsurance applies to your plan). But here’s some good news: There is a limit to how much you are required to pay. It’s called your out-of-pocket maximum (OOPM). And it is the most you’ll have to pay during a policy period – usually a year – for health care services.

If you are a current BCBSTX member, you can see your plan’s OOPM on your member ID card and in Blue Access for Members^SM. It’s different for every type of plan. Here are some things to keep in mind:

• Your OOPM limits how much you can be charged for your health care expenses. This limit protects you if serious and expensive medical issues come up.
• The government can change the OOPM each year. For 2025, the highest OOPM a plan can have is $9,200 for an individual and $18,400 for families. But some plans will have a lower OOPM.
• Remember, if you go out of your health plan's network for services, those expenses may not count toward your OOPM, and you could have to pay more.

Take this scenario for example:
Joe’s plan has a $9,200 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. But Joe has health insurance and stays in network. So he won’t have to pay more than $9,200 for covered expenses this year, even if his care costs more.

Read more about a deductible vs out of pocket maximum.

Before you choose a health insurance plan, it’s important to first consider your plan’s provider network. To see which providers are in a plan’s network, you can search online. Or log in to your BAM^SM account and click My Health in the top navigation. Then click Find Care to find a provider in your plan's network. 

Originally published 2/24/2015; Revised 2022, 2024