Out-of-Pocket (OOP) Limit

Also called “co-insurance limit” or “stop-loss limit”: the most you may have to pay during a benefit period (usually a calendar year) before your health insurance or plan begins to pay 100% of the allowed amounts. This limit never includes your premiums or non-covered services. Plans vary as to which coinsurance sums count towards your OOP limits: hospital, surgical, chemo & radiation coinsurance usually always count. Prescription and dental coinsurance & co-pays never count. Medical visits and diagnostics coinsurance may count on some policies. Deductibles and out-of-network coinsurance very rarely count. Always check to determine the definitions and OOP provisions in your Policy.