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Health Insurance Glossary

Definitions for common health insurance terms

out-of-pocket maximum

DEFINITION: A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual’s health care expenses.

For 2016, the maximum out-of-pocket (for in-network care that’s considered an essential health benefit) is $6,850 for an individual, and $13,700 for a family. There’s also a requirement starting in 2016 that individual maximum out-of-pocket limits be embedded in family plans.

For 2017, the maximum out-of-pocket limit will be $7,150 for an individual, and $14,300 for a family. Plans can have out-of-pocket limits below these thresholds however.