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Term Four: Deductibles and Out-of-Pocket Maximum Copy

A deductible is the amount of out-of-pocket expenses you must pay before the coinsurance starts to pay.

Out-of-pocket maximums or limits cap the amount you will pay each year for covered healthcare expenses.

Deductibles

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 Maximum

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.

You will not accumulate health care costs toward your deductible or out-of-pocket maximum on following items.

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.