Out-of-Pocket Maximum

Monthly premium payments — The annual out-of-pocket maximum caps the insured's share of covered medical costs, including deductibles, copayments, and coinsurance, during the policy year. Premiums are never counted toward that limit because they are the price of maintaining coverage itself, not a cost of receiving care. Under the contract-terms material in AH-III.A.1d, distinguishing what is and is not included in the out-of-pocket maximum is a standard exam question because it requires understanding that cost-sharing, not premiums, is capped.

National insurance concept

Monthly insurance premiums — The annual out-of-pocket maximum is the most the insured can be required to pay for covered, in-network essential benefits in a plan year. Deductibles, coinsurance, and copayments all count toward that maximum. Premiums do not: the premium is the price of coverage itself and is never counted toward the out-of-pocket cap. Amounts paid for non-covered services and out-of-network charges above the plan's allowed amount also generally do not count. Once the maximum is reached, the plan pays 100 percent of covered in-network costs for the remainder of the year.

National insurance concept