What is an out-of-pocket maximum?

What is an out-of-pocket maximum?

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.

  • Your health Insurance plan may require you to pay for some expenses out of your own pocket when you need care
  • The OOPM limits how much you can be charged for these expenses — protecting you in case of serious and expensive medical problems
  • The government can change this each year, and the maximum OOP cannot go over this amount. For 2015, the highest OOPM a plan can have is $6,600 for individuals and $13,200 for families. If you selected a bronze plan, your OOPM will be closer to $6,000, and if you purchased a gold or platinum plan, your OOPM will be lower than that.
  • If you go out of your network for services, those expenses may not count toward your OOPM, so you could have to pay more.

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:


Cost of an in network service:   $10,000
Joe’s copay :    $250
Joe’s coinsurance : 20% or    $2,000
Joe’s OOPM          $6,000

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!

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