Understanding Your Deductible and Out-of-Pocket Maximum

Your deductible and out-of-pocket maximum are two important numbers to understand when using your health plan, but it’s easy to confuse what each means.

Your deductible is the amount you generally pay for covered healthcare services before your health plan begins sharing the cost. Depending on your plan, some services may be covered before you meet the deductible, while others may require you to meet all or part of it first.

Your out-of-pocket maximum works differently. It is the most you may have to pay during the plan year for covered, in-network healthcare services that count toward the limit. Once you reach that amount, your health plan generally pays 100% of covered, in-network services for the remainder of the plan year.

Remember, reaching your deductible does not mean you are finished paying for healthcare. After meeting the deductible, you may still have copays or coinsurance until you reach your out-of-pocket maximum.

For example, if your plan has a $2,000 deductible, meeting that $2,000 does not necessarily mean the plan begins paying 100% of your healthcare costs. You may begin sharing costs with the plan through coinsurance or copays. Those eligible expenses can continue to accumulate toward your out-of-pocket maximum.

Understanding where you stand with both numbers can be especially helpful later in the year. If you have already met a significant portion of your deductible or out-of-pocket maximum, it may be worth reviewing your benefits and considering the timing of healthcare you’ve been putting off or know you’ll need.

Your plan documents can tell you which expenses count toward your deductible and out-of-pocket maximum, as well as which services may be covered before you meet your deductible.

CalCPA Health Members

To see where you currently stand with your deductible and out-of-pocket maximum, you can download the Anthem Sydney Health app or log in to your Anthem account to view your claims and track your year-to-date deductible and out-of-pocket costs.