The out-of-pocket maximum is the most you can pay in a plan year for in-network covered services. Once your deductible, copays and coinsurance add up to it, the plan pays 100% of covered in-network care for the rest of the year.
Three exclusions that make the “maximum” less maximum than the word suggests:
- Premiums don’t count. What you pay monthly to have the plan is separate.
- Out-of-network care usually doesn’t count, or counts against a separate, higher limit.
- Non-covered services never count — anything the plan excludes is outside the accounting entirely.
Practical use: if you know a surgery is coming, the out-of-pocket maximum tells you your realistic worst case for the year, and it often makes a higher-premium plan cheaper overall. If a big expense already happened this year, additional care before December 31 may cost you nothing — the timing of an elective procedure is worth a conversation.
For uninsured New Yorkers there is no out-of-pocket maximum, which is why hospital financial assistance is the functional equivalent: state law, not a plan, sets the ceiling.
Also called: out-of-pocket limit, OOP max. Reference: Out-of-pocket maximum on Wikipedia — general definition, not New York specifics.
More in Glossary of health coverage and billing terms
- Federal poverty level (FPL) — A federal income benchmark, updated each January, that decides eligibility for most health programs in New York.
- Deductible — The amount you pay yourself each year before the insurance plan starts paying its share.
- Copay — A fixed amount you pay for a specific service — $25 for a visit, $10 for a generic drug.
This page explains how the system works. It is not medical advice. More.