What the OOP max really is
Your Out‑of‑Pocket Maximum (OOP) is the absolute most you’ll pay for covered, in‑network services in a plan year. After you reach it, the plan pays 100% in‑network for the rest of the year.
Why it’s the most important number
Premiums and deductibles matter, but OOP max defines your worst‑case scenario. If you have an accident or surgery, the difference between an $8,700 and $5,500 OOP max can mean thousands saved.
How you get there
All in‑network copays, deductible payments, and coinsurance generally count toward the OOP max. Out‑of‑network spending usually does not. Balance bills don’t count either.
Examples
- Healthy year: You never reach the OOP max. Your costs stay at copays/deductible levels.
- Major year: After an expensive hospitalization, you hit OOP max and then pay $0 for additional covered in‑network care.
How True North Roots uses OOP in recommendations
We model total‑year costs, not just premium. If you expect care, a plan with a slightly higher premium but a much lower OOP max can be smarter. We’ll show side‑by‑side scenarios before you choose.
Need help deciding? True North Roots can compare plans, estimate your subsidy, and enroll you at no cost.