<img height="1" width="1" style="display:none" src="https://www.facebook.com/tr?id=1035411413176864&amp;ev=PageView&amp;noscript=1">

Insurance For Texans Blog

All the Insurance Topics a Texan Could Want

    What Is a Maximum Out of Pocket on Health Insurance

    Posted by Kevin Hall on Jul 28, 2023 9:45:00 AM

    When considering health insurance plans, it is important to understand the financial implications of your coverage. One key aspect to consider is the Maximum Out of Pocket (MOOP) limit. The MOOP serves as a cap on the amount you will have to pay for in-network covered healthcare services during a policy period. This limit includes deductibles, copayments, and coinsurance payments, but does not include your monthly premiums. Understanding how to use the MOOP can help you compare health insurance plans and make an informed decision about your coverage.

    Click To Get Help With Health Insurance

    While many Texans routinely ask the agents at Insurance For Texans about their deductible as a leading question, we believe that the Out of Pocket Maximum is far more important since it is the amount of money that you have risk in the event of a major health event. Knowing where your financial risk ends and where the health insurance company will begin paying at 100% of your bills is incredibly important. Let's dig into some details.

    Why Knowing Your Maximum Out of Pocket is Important

    Knowing your Maximum Out of Pocket (MOOP) limit is crucial when evaluating health insurance plans, as it can protect you from high and unexpected medical costs. This out of pocket max serves as a cap on the amount you will have to pay for covered healthcare services during a policy period. 

    To illustrate the importance of the out of pocket maximum, let's consider the example of you needing your appendix removed. Without health insurance, this procedure can cost thousands of dollars, potentially creating a financial burden. However, with the right health insurance plan, the out of pocket maximum can help limit how much money you would have to pay out of pocket for this procedure, providing significant cost savings. Since it sets an upper limit on the amount you will have to pay during a year, it can bring peace of mind and financial security to your family's plans.

    When comparing health insurance plans, understanding the MOOP allows you to assess the level of protection each plan offers. Plans with a lower out of pocket max generally provide greater financial security but also have higher monthly insurance premiums. On the other hand, plans with higher MOOP limits typically have lower monthly premiums. Their downside is that the health insurance company offering the policy will require you to shoulder a greater share of medical costs. So what else do you need to know?

    What Is a Maximum Out of Pocket on Health Insurance?

    Types of Maximum Out of Pocket Limits

    When evaluating your health insurance options and looking at the MOOP rather than the deductible as a key driver of value, it is important to understand some details about not only the components that make up the out of pocket max, but also the types of MOOP being applied to your health care costs. One type is the individual MOOP, which applies to each insured person on the plan. Another type is the family MOOP, which limits the total amount a family would have to pay for covered services for all people on the insurance plan. Some plans may have separate MOOP limits for in-network and out-of-network providers and locations. It's important to carefully review the details of each plan's MOOP limits, as they can be wildly different and significantly impact your out-of-pocket costs. With that in mind, let's look at the individual components of the money that you will pay for healthcare costs to fulfill your out of pocket max.


    When it comes to health insurance plans, understanding the concept of a deductible is important. A deductible is the set amount of money you must pay out-of-pocket for healthcare services before your insurance kicks in and starts covering the costs. Deductibles can vary depending on the health insurance plan you choose and the monthly premiums you pay.

    Once you've reached your deductible, your insurance company will start to pay a portion of your healthcare costs. This can take the form of a copayment, where you pay a flat fee for certain services, or coinsurance, where you pay a percentage of the costs.

    When evaluating how deductibles work and comparing them across different health insurance plans, consider your healthcare needs and budget to determine what level of deductible is right for you. By doing so, you can better manage your expenses while also keeping an eye towards your maximum out of pocket.


    Coinsurance is the percentage amount of a bill for covered medical care that you, as the insured individual, have to pay. Your insurance company covers the remaining percentage. For example, if your health insurance plan has a coinsurance rate of 20%, this means that you will be responsible for paying 20% of the cost of your medical bills, and your insurance company will cover the remaining 80%. This can be especially important for individuals with substantial health care usage or for more expensive treatments or procedures.

    Understanding coinsurance is important because it directly impacts how quickly you can reach your out-of-pocket costs for medical services. It is important to know the percentage amount that you will be responsible for, as it can vary significantly depending on your health insurance plan. Having a 10% coinsurance versus a 40% coinsurance will change how quickly you can blow through the gap between your deductible and you out of pocket max for something as simple as an ER trip for a broken arm.

    By understanding coinsurance and carefully evaluating the percentage amounts in different health insurance plans, you can make an informed decision that best suits your healthcare needs and budget.


    A copayment, often referred to as a copay, is a fixed amount that a health insurance policyholder is required to pay for specific covered health care services. Unlike coinsurance, which is a percentage of the cost of the service, a copayment is a set fee that remains consistent regardless of the total cost of the service.

    When you receive a covered health care service, such as a doctor's visit or a prescription medication, you may be responsible for paying a copayment before or at the time of service. For example, let's say your health insurance plan has a copayment of $25 for primary care doctor visits. If you visit a primary care physician for a covered service, such as a routine check-up, you would pay the $25 copayment while your insurance company would cover the remaining cost.

    It is important to consider not only the copayment amounts but also if their payments are applied to either your deductible or MOOP. Many individual plans do not apply copays towards your deductible or MOOP even if the visit is an in-network service. Understanding how copayments work and when they are required can help you make an informed decision about which plan best fits your needs and budget.

    Total Maximum Out of Pocket (MOOP)

    The MOOP combines the various costs of your health insurance plan, including deductibles, coinsurance, and possibly copayments, to determine the maximum amount you will pay for covered services within a calendar year. Once you reach the MOOP for the year, your insurance company will cover 100% of any additional in-network covered services.

    It's important to note that certain expenses, such as your monthly premiums, may not be included in the MOOP limit. Additionally, services that are not covered by your insurance plan, like elective procedures or out-of-network care, will not count towards your MOOP.

    Understanding the concept of the Total Maximum Out of Pocket can help you analyze and compare health insurance plans more effectively. By considering the potential out-of-pocket costs, you can choose a plan that provides the necessary coverage while also fitting your budget.


    Subscribe Here For Regular Updates


    High-Deductible Health Plans (HDHP) and Maximum Out Of Pocket Limits

    When it comes to evaluating health insurance plans, understanding the terms and coverage options can be overwhelming. For people considering different health insurance plans, it can be hard to determine which one is truly better for you. Lets evaluate high-deductible health plans (HDHP) in Texas and how the MOOP applies to them so that you can compare them against a more traditional health insurance policy.

    1. What are high-deductible health plans (HDHP)?

    High-deductible plans (are health insurance plans that require policyholders to pay 100% of their healthcare costs prior to hitting a higher deductible before the insurance coverage kicks in and begins reimbursing you. These plans typically have lower monthly premiums, making them an attractive option for those looking to save on premium costs. However, it's important to note that HDHPs have that stipulation that you will be paying full price for even in-network costs at first. For some Texans, this feels scary.

    2. Understanding the maximum out-of-pocket (MOOP) limit

    Reaching your maximum out-of-pocket (MOOP) limit on a traditional health insurance policy includes deductibles, coinsurance, and possibly copayments. For a high deductible plan, it is typically you paying for services up to your deductible that will contribute to your MOOP. With many high deductible plans, the deductible is equal to the out of pocket max.

    3. Using the MOOP limit to compare HDHPs

    In a twist of fate that is primarily due to you not leveraging copays to pay for covered benefits, the MOOP for a high deductible plan is usually LOWER than the MOOP of a more traditional health plan. This is especially true of Health Insurance Marketplace plans. 

    4. Additional factors to consider

    The final consideration, will come down to two things. Your monthly premiums and your ability to pay cash up front for in-network providers, prescription drug coverage, doctor visits and any additional medical care that is covered by your plan until you reach the magic deductible. The one exception to the need to pay cash for qualified health coverage would be for preventive care. Plans sold through the health insurance marketplace will come with Preventive Care falling under the minimum essential components of the Affordable Care Act provisions.

    HDHP Benefits

    High-Deductible Health Plans (HDHPs) offer both benefits and requirements for policyholders. These plans generally have higher deductibles, meaning that individuals must pay a certain amount out of pocket before their insurance coverage begins. However, they often come with lower monthly premiums, making them an appealing option for cost-conscious individuals.

     The main benefit of a high deductible health plan is that you are eligible to contribute to a Health Savings Account when the plan is an HSA-Qualified Health Plan. This key tool will allow you to move pre-tax money into an account that can grow over a long time frame to plan for future health care costs. This feature is even better when you realize that any gains or interest that accrue over time are also tax free on the backend if the funds are used for qualified medical expenses.

    Given this key benefit along with lower premiums and lower out of pocket max limits, these plans become very appealing to many Texans. But it's important to assess if your budget has room to cover the cash cost of a visit before plans begin covering your medical expenses after the deductible is met.

    If you fall into this category, the MOOP allows you to assess the maximum amount you will have to pay out of pocket for covered medical services in a given year. This is especially important for individuals who anticipate substantial health care use or have ongoing medical needs. By comparing the MOOP limits of different health insurance plans, you can identify the level of financial protection each plan offers. Lower monthly premiums by themselves can be appealing, but understanding the downstream costs of your medical care and its effect on your cash flow can help you better plan for your upcoming year.

    If you are unsure which plans would work best for you, speak with an agent at Insurance For Texans today. Our independent insurance agents work for you rather than some big company. They can help you with the Health Insurance Marketplace along with private health insurance plans to meet all of your needs.

    If you are considering an HSA-Qualified health plan, our agents have years of experience helping Texans sort out their available options. Click the button below or call us at 469.789.0220.

    Click To Get Help With Health Insurance

    Topics: deductible, health insurance, ACA, catastrophic health coverage, ACA Alternatives, Obamacare