There are a number of expenses that may not count toward the out-of-pocket maximum:
- Care and services that aren’t covered: Your health plan may not cover some types of services. This could include things like cosmetic treatments, weight loss surgery, and some alternative medicine.
- Costs above the allowed amount: Most plans set an allowed amount for various services. If a doctor or facility charges more than that, your plan is not going to cover that cost. This means it will not be applied to your out-of-pocket maximum, either. Make sure to check the details of your plan.
- Out-of-network care and services: Most health plans have a network of doctors. These doctors agree to give plan customers discounted rates for using their services. If you go to doctors or facilities that do not participate in your plan’s network, your costs may not be covered.* What you pay for out-of-network care may not be applied to your out-of-pocket maximum. It’s important to ensure providers are in your plan’s network before seeing them.
- Plan premiums: If you buy a health plan on your own and not through your employer you typically have a monthly plan premium. This cost doesn’t count toward your out-of-pocket maximum.
- Most preventive care: Many health plans cover most preventive care at 100%, as part of the Affordable Care Act (ACA). This is routine care like an annual check-up, some lab tests, flu shots and some other vaccinations, and routine screenings like an annual mammogram and colonoscopy. These preventive services are paid for by your health plan, so their costs do not count toward the out-of-pocket maximum.
- Plan deductibles (in some cases): For some health plans the out-of-pocket max may not include costs that go toward your deductible. Make sure you understand the details of your health plan when choosing coverage.