Below is the definition of deductibles and out-of-pocket maximums:
Not all items are equal in being included in your deductible and out-of-pocket maximum:
| What counts towards your deductible | What does not count to your deductible |
|---|---|
| Generally anything listed as “after deductible” in your plan document. Only the money you pay counts, not what the insurer also contributed | Co-pays (Though co-pays do count towards out-of-pocket maximums) |
| Generally anything where you don’t pay a co-pay (flat fee) | Routine vision and dental work since that is covered by a separate insurance plan |
| Medications may be covered by a separate Pharmacy Benefit Manager (PBM). (Though medications may count towards out-of-pocket maximums) | |
| Premiums | |
| Be aware that payments towards out-of-network providers are counted in an entirely separate bucket. The deductibles and out-of-pocket maximums for out-of-network care are often much higher | |
| Anything covered by your insurer at 100% | |
| Balance billing by the provider | |
| Procedures that are denied by your insurer, such as experimental treatments, cosmetic surgery, procedures deemed unnecessary by your insurer |
Family health insurance plans often have both an individual deductible and a family deductible/out-of-pocket maximum.
Individuals are allowed to continue spending towards their individual deductibles and out-of-pocket maximums, until the combined dollar amount for the entire family reaches the family deductible or out-of-pocket maximum. At that point all further medical care for all individuals is either paid at the coinsurance amount after the family deductible has been met, or nothing at all if the family out-of-pocket maximum has been met.
