Out of Pocket Maximum

The definition of Out of Pocket Maximum, and how it fits into the Zenefits Health Insurance Marketplace

What are out of pocket maximums?

An insurance plan’s Out-of-Pocket (OOP) maximum is how much someone will have to spend on healthcare before the insurance carrier will cover 100% of their medical expenses.


How does an out of pocket maximum work?

If an employee selects a plan with a $5,000 OOP max and spends $5,000 out of pocket by mid-year, any medical costs that are incurred for the rest of the plan year will be 100% covered by their insurance company.

The OOP maximum does not carry over from plan year to plan year — it resets with the plan year, much like deductibles.