What Is an Out-of-Pocket Maximum?

An out-of-pocket maximum is the most you have to pay for covered healthcare services in a plan year before your insurance covers 100% of additional costs. This includes deductibles, copays, and coinsurance but does not count premiums or services not covered by your plan.

How does it work?

• Original Medicare: There is no annual out-of-pocket maximum, meaning costs for Part B services (like doctor visits and outpatient care) continue throughout the year. However, some beneficiaries purchase a Medigap plan to help with expenses.
• Medicare Advantage (Part C): These plans include a set out-of-pocket maximum, which can vary but is capped by federal regulations. In 2024, the maximum is $8,850, though many plans have lower limits.
• Private insurance plans: ACA-compliant marketplace plans and employer-sponsored insurance must include an out-of-pocket maximum, with limits set annually by federal guidelines.

How Solace can help

A Solace advocate can help you understand your out-of-pocket costs, explore supplemental coverage options, and determine if you're eligible for financial assistance programs to lower expenses.

What to do next

Ready to explore coverage options, financial assistance, and other ways to reduce out-of-pocket expenses? Find an advocate today.