The out-of-pocket maximum is the total amount Blue Cross Blue Shield of Massachusetts requires you to pay for certain health care services in a plan year. It is designed to limit the total amount you pay each plan year. Once you meet your out-of-pocket maximum for the year, most remaining costs for in-network services are paid in full. However, you may still be responsible for copays for certain services and any additional costs for out-of-network services. The out-of-pocket maximum details for your plan can be found in your Summary of Benefits.
Here's an example:
Ivy's health plan has a $2,500 out-of-pocket maximum for the year, and Ivy needs surgery to repair a tendon in her knee. This type of surgery is a covered expense. The surgery will cost $9,000. As long as Ivy uses an in-network doctor and hospital, the most she will pay for her surgery is $2,500 ($1,000 of this is her annual deductible) and Blue Cross Blue Shield of Massachusetts will cover the remaining balance.
If after the surgery, Ivy requires medication and her plan has a pharmacy benefit, depending on her plan, she may be responsible for her pharmacy copayments. And if later in the year, she has a high fever and goes to see her primary care doctor, it is also possible she may have a copayment.
For more information on the out-of-pocket maximum for your plan, please see your Summary of Benefits.