What does out-of-pocket maximum (OOPM) mean in plan design?

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Study for the Wellcare ACT Mastery – Broker and Employee Exam. Prepare with our comprehensive materials including flashcards and multiple choice questions, with detailed hints and explanations. Achieve excellent results in your exam!

Multiple Choice

What does out-of-pocket maximum (OOPM) mean in plan design?

Explanation:
The out-of-pocket maximum is the cap on what a member pays for covered health care services within a plan year. It includes the amounts you pay through the deductible, coinsurance, and copays for services that are covered by the plan. Premiums do not count toward this limit. Costs for services that aren’t covered by the plan also don’t count toward the maximum. In most plans, once you reach this limit, the plan covers 100% of remaining covered in-network costs for the rest of the year. This is why the correct description is that it’s the maximum amount a member pays for covered services in a plan year.

The out-of-pocket maximum is the cap on what a member pays for covered health care services within a plan year. It includes the amounts you pay through the deductible, coinsurance, and copays for services that are covered by the plan. Premiums do not count toward this limit. Costs for services that aren’t covered by the plan also don’t count toward the maximum. In most plans, once you reach this limit, the plan covers 100% of remaining covered in-network costs for the rest of the year. This is why the correct description is that it’s the maximum amount a member pays for covered services in a plan year.

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