Deductible vs. Out-of-Pocket Max?

What exactly is the difference between a "deductible" and the "out-of-pocket maximum"?


In the Deductible health plan, when you get medical care, you must pay the initial bills before you are fully covered by the insurance (except for your annual preventative exams).

The deductible for an individual is $1,000. Once you have paid that deductible, then the insurance begins to make payments on your behalf, though you still typically pay a portion of the bills (20% in many cases).

Once you have paid out a total of $1,500 (for an individual) you have reached your out-of-pocket maximum. That means that the insurance will now cover you at 100%, including your prescriptions, for the remainder of the plan year.

If I am have family coverage, do I have to pay $1,500 for each family member?

No! The above numbers still apply for an individual; however, as a family unit your deductible is $2,000, and your out-of-pocket maximum is $2,500.

For instance, let's say you reach your individual $1,500 out-of-pocket maximum for the year— the remainder of your expenses are now covered for the plan year—once your spouse and/or children collectively have $1,000 worth of expenses. Now your family's out-of-pocket maximum also has been reached, and all family members are covered 100% for the remainder of the plan year.