Individual out-of-pocket (OOP) limit
In general, this is the most one person will pay for covered services during a plan year, and then the plan begins to pay 100% for covered services. See your plan documents for exceptions.
You won't need to meet individual OOP limit if costs paid for everyone on your plan, combined, reach the family OOP limit.
Some plans have two different out-of-pocket limits
- Costs for providers in your plan's network apply to your "in-network" or "preferred" out-of-pocket limit.
- Costs for providers outside your plan's network apply to your "out-of-network" or "alternate" out-of-pocket limit.
Costs included in your individual OOP limit
- Costs that apply to your deductible
- Coinsurance (when you pay a percentage of the cost of a medical service and your plan pays the rest)
- Copayments (fixed dollar amounts) for doctor visits and other services
Some costs don't count towards your OOP limit
Premiums and the cost of services your plan doesn't cover don't count towards your OOP limit. Other costs may be excluded by your plan; see your plan documents for details.