What is an out-of-pocket maximum?

An out-of-pocket maximum is the most you have to pay out-of-pocket for your health care costs in a year. In North Dakota, it is set by the health insurance plan you have and usually includes deductibles, copays and coinsurance. The out-of-pocket maximum is the maximum amount you are expected to pay for covered services in a year before your health plan pays 100% of the allowed amount for covered services. This includes payments made for prescription drugs, in-network doctor visits, and hospital stays. The out-of-pocket maximum does not include premiums, balance billing amounts for services from out-of-network providers, or health care services that your health plan does not cover. The out-of-pocket maximum helps protect you from having to pay too much for your health care services in a year. After the out-of-pocket maximum is met, you are no longer responsible for costs associated with health care services, and your health plan will cover the remaining costs associated with in-network services.

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