Out-of-Pocket Maximum
The cap on what a patient pays in a plan year, after which the plan covers 100%.
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The out-of-pocket maximum is the most a patient will pay for covered, in-network services in a plan year. Once deductible, copays, and coinsurance add up to this cap, the plan generally pays the full allowed amount for further covered services.
It resets with the plan year, and what counts toward it is defined by the plan.
Why it matters for billing
A patient who has met their out-of-pocket maximum owes nothing more for covered services — billing them anyway creates refunds and friction. Knowing where a patient stands prevents both over-collection and missed collection.
Related terms
Terms that come up alongside Out-of-Pocket Maximum in the revenue cycle.
Billing that gets Out-of-Pocket Maximum right
EnVisionMD RCM handles eligibility, coding, documentation, denials and follow-up end to end — so the details behind terms like this one are managed for you, not left to chance.
Request a free billing reviewOut-of-Pocket Maximum — frequently asked questions
The plan generally pays the full allowed amount for further covered, in-network services for the rest of the plan year.
Yes, typically at the start of each plan year.