Direct answer: A deductible is the amount you pay for covered services before coinsurance typically begins, subject to the plan. An out-of-pocket maximum is the most you pay in a year for eligible in-network cost sharing. After you reach that cap, the plan generally pays 100 percent of additional covered in-network services for the rest of the year. Premiums, non-covered services, and some out-of-network bills may stay outside the cap.
How do the two numbers work in sequence?
For many plans, you pay eligible costs toward the deductible first, except for services the plan covers before the deductible, such as required preventive care. After the deductible, you may pay copays or coinsurance until eligible spending reaches the out-of-pocket maximum. The out-of-pocket maximum explainer on this site covers what usually counts and what does not. This page is the comparison between the two figures, with a labeled hypothetical.
Hypothetical example only, not a real plan
The figures below are round numbers invented for illustration. They are not premiums, quotes, or figures from any carrier or Marketplace plan.
Suppose a plan has a $1,000 in-network deductible and a $5,000 in-network out-of-pocket maximum, and it charges 20 percent coinsurance after the deductible for a covered hospital stay. If the plan's allowed amount for that stay is $10,000, you would pay the $1,000 deductible first. The remaining $9,000 allowed amount at 20 percent would be $1,800. Your eligible cost sharing for that stay would be $2,800, and $2,800 would count toward the $5,000 out-of-pocket maximum, if the plan credits those amounts. Later eligible copays and coinsurance would continue until credited spending reached $5,000. After that, additional covered in-network services would generally be paid at 100 percent for the rest of that plan year. If the hospital billed more than the allowed amount and balance billing was permitted, that extra amount might not count. This example ignores copays, separate drug deductibles, family embedded limits, and out-of-network rules.
What usually does not count?
Monthly premiums. Services the plan does not cover. Charges above the allowed amount where balance billing is allowed. Out-of-network costs when the plan does not credit them. Amounts that fail referral or prior-authorization rules. Always use the Summary of Benefits and Coverage for the exact plan.
How should I use these numbers when choosing a metal level?
A lower-premium plan can have a higher deductible. A higher-premium plan can have a lower deductible. Neither fact tells you which household will pay less for the year. Combine the deductible, out-of-pocket maximum, expected prescriptions, and network. See Bronze vs Silver vs Gold and the plan documents for the year you are comparing.
Do family plans use one cap or two?
Family coverage may include an individual embedded deductible or out-of-pocket limit and a family aggregate. One person can meet an individual cap while the family cap still applies to others. The Summary of Benefits and Coverage shows how the exact plan credits each member.
Prescription costs may use the same out-of-pocket maximum or a separate drug deductible. That split is why a hospital example is incomplete if you take expensive medications. Check both sections of the document.
The hypothetical dollar figures earlier on this page remain examples only. Do not treat them as Lakeland averages or as quotes.
Do premiums and non-covered services count?
Monthly premiums generally do not count toward the deductible or the out-of-pocket maximum. Services the plan does not cover generally do not count either. Out-of-network amounts may have a separate deductible and cap, or none. The Summary of Benefits and Coverage is the document to read for the exact plan.
The labeled hypothetical on this page uses round numbers only as an illustration. Your plan will not match those figures. See the longer out-of-pocket maximum guide for more structure, and confirm the live contract before you enroll.
If a denial says a service is excluded, appealing the claim will not make it count toward the maximum. See what to do if a plan denies a claim.
What to do next
Read the deductible, out-of-pocket maximum, and exceptions on the Summary of Benefits and Coverage for each plan ID you are considering. David Huff, a licensed Florida health agent, can walk through those documents. Call (863) 640-3102 or use Get Help.
Compare deductible and out-of-pocket maximum on the same plan ID
Bring the Summary of Benefits and Coverage. Hypothetical numbers on this page are examples only.
Request a Plan Review Call (863) 640-3102Sources
The dollar figures in the example are hypothetical and are not plan quotes. Actual deductibles, coinsurance, allowed amounts, and out-of-pocket maximums are controlled by the plan documents.