The deductible applies to different parts of different policies. For example, you may have to pay out-of-pocket for x-rays, CT scans, or surgeries until your deductible is satisfied, but not for lab tests like bloodwork. With some policies, the deductible must be met before the plan starts to pay for prescriptions, and with other policies, prescription coverage is not dependent on meeting a deductible.
Out-of-pocket maximums or limits cap the amount you will pay each year for covered healthcare expenses. Limits help you control how much you will pay in total for health coverage services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
Your monthly premium payments
Costs for services your plan doesn’t cover
Unapproved out-of-network care and services
Costs above the insurance’s allowed amount for a service
The out-of-pocket limit for health insurance varies but can’t go over a set amount each year. For the 2021 plan year, the out-of-pocket maximum for a Healthcare.gov plan can’t be more than $8,550 for an individual and $17,100 for a family for services that are considered in-network.