An out-of-pocket maximum, also known as “stop loss,” is an important feature of Medicare Advantage plans, which protects you from excessively high medical costs.
All of the dollars you spend on approved medical expenses throughout the year (such as copays at your doctor visits) add up to your out-of-pocket maximum amount. This amount differs from plan to plan. If the amount you spend in copays hits the out-of-pocket maximum for your plan, then going forward the plan steps in to pay your share of approved medical expenses for the remainder of the year.
Here’s an Example
Bob’s plan has an out-of-pocket maximum of $4000. In February, Bob visits his doctor for the first time of the year and pays his copay of $30 for the visit. The remaining amount for the year that Bob can expect to pay for approved medical expenses like this should be around $3970.
Maximum out-of-pocket amounts can vary from plan to plan. To find out what your plan’s out-of-pocket maximum is, you can consult your Summary of Benefits or contact our Client Services team at 1-877-222-1942 or firstname.lastname@example.org.
For more information on how out-of-pocket maximums work, watch this video.