What to do after hitting out-of-pocket max?


Editorial team Published on

Once you reach your annual out-of-pocket maximum, your health insurance plan covers 100% of the cost for eligible, in-network services for the rest of the plan year.

Verify Your Status

  • Confirm with your insurer: Call customer service or check your online portal to ensure they have processed all claims and officially recorded that you have met your limit.
  • Check network status: Verify that your providers are in-network, as out-of-network care usually does not count toward the cap and is not covered at 100%.
  • Track EOBs: Compare your provider bills with your Explanation of Benefits (EOB) statements to make sure you aren't billed for covered services.

Schedule Needed Care

  • Get elective procedures: If you or a doctor have considered elective or non-emergency surgeries (like joint repairs, hernia corrections, or physical therapy), getting them done before the year ends means they are fully covered.
  • Book specialist and diagnostic visits: Schedule lingering check-ups, dermatological mole evaluations, specialist referrals, MRIs, or lab tests now.
  • Refill prescriptions: Ask your doctor for extended 90-day or 6-month supplies of long-term medications to carry you through to the next year.
  • Stock up on medical supplies: Order any durable medical equipment or regular non-perishable medical supplies covered by your plan.

Keep in mind that your out-of-pocket maximum resets at the start of every calendar or policy year, meaning you will go back to sharing costs when the new period begins.