Cost-sharing
Out-of-pocket maximum (OOP max)
The most you will pay for covered in-network care in a plan year. Once you hit it, the insurer covers 100% of remaining covered services. Federal law caps annual OOP max amounts; CMS publishes the limit each plan year. The OOP max includes deductibles, copays, and coinsurance — but not premiums.Last reviewed: · TMRW Benefits is a benefits brokerage, not a tax or legal advisor. Consult a CPA or attorney for situation-specific guidance.
More in Cost-sharing
Premium
Monthly payment to keep coverage active.
Deductible
Out-of-pocket amount you pay before insurance starts paying.
Copay
Flat fee per service. Often not subject to the deductible.
Coinsurance
Percentage of cost you pay after deductible.
Allowed amount
Maximum the plan considers reasonable for a service.
Balance billing
Out-of-network provider bills you the gap.
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