What Is an Out-of-pocket Maximum?

What Is an 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, coinsurance and copays. 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 BCBSOK member, you can see your plan’s OOPM in Blue Access for MembersSM. 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 2022, the highest OOPM a plan can have is $8,700 for an individual and $17,400 for families. If you selected a Blue Advantage Bronze HMO Plan or Blue Advantage Plus Bronze HMO Plan, your OOPM will be $7,000 per individual. With a Blue Advantage Gold HMO Plan, your OOPM will be even lower.
  • Remember, if you go out of your 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 $8,700 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 $8,700 for covered expenses this year, even if his care costs more.

Read more about a deductible vs out of pocket maximum.

Before you even choose a health insurance plan, it’s important to first consider your plan’s doctor network. Our Provider Finder® tool will help you know if your doctor and hospital of choice are in a plan's network.

It’s a lot to digest, so if you still have a few questions about your out-of-pocket maximum, ask us in the comments!

Originally published 8/19/2015; Revised 2022