Medical out-of-pocket limit
On this page
The medical out-of-pocket limit is the most you pay during a calendar year for covered services from network providers. Once you meet this limit for the year, the plan pays 100 percent of the allowed amount for covered services from network providers.
- $2,000 per person.
- $4,000 maximum per family (two or more enrolled under one subscriber’s account).
Your coinsurance paid to network providers:
- Primary Care Network providers.
- Specialty Network providers (including ancillary providers).
- Inpatient and emergency room copays.
- Your medical deductible.
- Amounts paid by the plan, including services covered in full (preventive).
- Prescription drug costs. See how the prescription drug out-of-pocket limit works (which is counted separately by Washington State Rx Services).
- Your coinsurance paid to non-network and out-of-network providers (note that non-network and out-of-network coinsurance does count toward your medical deductible).
- Balance billed amounts (see definition of balance billing below). For exceptions, see “Exceptions: Out-of-network provider services that count” below.
- Services not covered by the plan (see examples).
- Amounts that are more than a maximum dollar amount paid by the plan. For example, the plan pays a maximum of $150 for adult vision hardware once every two calendar years. Any amount you pay over $150 does not count toward the medical out-of-pocket limit.
- Amounts paid for services exceeding a benefit limit. For example, the benefit limit for acupuncture is 16 visits. If you have more than 16 acupuncture visits in one year, you will pay in full for those visits, and what you pay will not count toward this limit. See Limited benefit for more benefits with this type of limit.
You will still be responsible for paying numbers 2–7 above after you meet your medical out-of-pocket limit.
Services by non-network and out-of-network providers are paid at 50 percent (see below for exceptions). Even after you meet your medical out-of-pocket limit, you will still pay 50 percent coinsurance for non-network and out-of-network provider services. Out-of-network providers may balance bill* you.
Note that the 50 percent you pay and balance billed amounts do not count toward your medical out-of-pocket limit. However, coinsurance paid to non-network and out-of-network providers does count toward your medical deductible. Balance billed amounts never apply toward your medical deductible.
Exceptions: Non-network and out-of-network provider services that count toward your medical out-of-pocket limit
When you receive the services listed below, your coinsurance and balance billed* amounts for non-network and out-of-network provider services will count toward your out-of-pocket limit. In addition, the plan will pay 100 percent of billed charges for these services after you meet your medical out-of-pocket limit.
- Cochlear Implant Processor Supplier.
- Ocularists (creation and fitting of prosthetic eyes).
Additional exception for approved network consent services
In addition to the services above, your coinsurance for non-network and out-of-network provider services related to an approved network consent will count toward your medical out-of-pocket limit, and the plan will pay 100 percent of the allowed amount for these services after you meet your medical out-of-pocket limit.
*Balance billing is a provider billing you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. Only out-of-network providers may balance bill you for covered services above the allowed amount. See an example of how this works.