Insurance Glossary

Insurance Term - Out-of-Pocket Maximum

The total amount a policyholder will be required to pay ‘for covered medical services’ during a specified period, such as one year. The out-of-pocket maximum may also be called the stop-loss limit or catastrophic expense limit. In other words, Out-of-Pocket Maximum is defined as the amount the policyholder/insured is required to pay under a plan or insurance contract. An individual will be required to pay a fixed amount for deductibles and co-insurance for the covered services during the course of a benefit period. Once the Out-of-Pocket Maximum is met, most covered services are paid at 100 percent of the allowed amount.

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