Health Care 101: Benefit Maximums

July 8, 2019

As part of an ongoing series about health care terms, below describes plan design components related to how much you and the plan will pay for services.

Benefit Term What It Means
Benefit Maximums Some health care services have a benefit maximum. This is the most your health plan will pay in a given calendar year, or lifetime, toward certain covered expenses
Out-of-Pocket Maximum The most you will pay out-of-pocket in a calendar year for covered expenses. Once you reach the out-of-pocket maximum, the Plan will pay 100% of covered expenses for the rest of the calendar year; excluding any expenses above a benefit maximum for a particular service.
“Your Responsibility” as listed on an Explanation of Benefits (EOB) Every time you receive medical care, you’ll get an EOB that shows the service, how much it cost, how much is covered by the Plan and how much you have to pay (i.e., your responsibility). If an expense is higher than a benefit maximum, if there’s limited coverage or if the coverage pays only a certain percentage of the expense, any remaining balance will be shown as “your responsibility” on the EOB.
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