Shuman Roy is an entrepreneur, business owner, and musician. He started RoysNoys, LLC in 2013 as a music production and education service company. He also offers small business consulting and advisory services to help businesses get from start-up mode to turn-key operations. Shuman earned his M.B.A from the Stern School of Business in 2001 and has an undergraduate degree from Manhattan College in ...

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Joel Ohman is the CEO of a private equity-backed digital media company. He is a CERTIFIED FINANCIAL PLANNER™, author, angel investor, and serial entrepreneur who loves creating new things, whether books or businesses. He has also previously served as the founder and resident CFP® of a national insurance agency, Real Time Health Quotes. He has an MBA from the University of South Florida. Joel...

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Reviewed by Joel Ohman
Founder, CFP®

UPDATED: Oct 20, 2021

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With the cost of health care coverage soaring, there is increasing concern among people regarding how much insurance can dent a personal or family budget. Especially when it comes to medical costs; it’s always nice to know that there are options.

Fortunately, you can easily calculate the worst case scenario for health insurance costs in a particular year if you know the ‘out-of-pocket maximum’ on your particular policy.

A typical out-of-pocket maximum for medical expenses might be $5,000 for a policy during the year.

What this means is that no matter how much you spend in health care costs during a single year, you will not be responsible for paying more than $5,000 of your own money.

But note that the cost of your insurance premium, whether paid in full at policy inception or over time via monthly payments, is not included in this figure.

Be certain to add the out-of-pocket maximum to your total premium to determine the maximum annual health insurance costs for yourself and/or your family.

So what costs are included in your out-of-pocket maximum?

Annual Deductible – As with most insurance policies, there is an insurance deductible in place, which is meant to deter frequent, potentially needless visits and use up unnecessary medical services. You pay the deductible amount prior to the insurance company pitching in one dollar.

This helps keep the cost of health insurance down for everybody, as settling even the smallest insurance claims can be costly for your insurance company. Your policy may have a flat family deductible, or a per-person deductible. It may seem strange for a company to attempt to deter its customers from using their health plan, but it’s to ensure that it’s only called on for a true emergency.

Co-Pay –This is the amount of money you are required to pay for a doctor visit or prescription drugs (any single event). For example, your policy may require you to pay 20 percent of the doctor visit and a flat rate of $20 for each prescription medication you obtain.

Co-Insurance – This is similar to a co-pay, but is typically an annual figure. For example, you may be required to pay 20 percent of your total annual healthcare costs after your deductible is met, up to your out-of-pocket maximum.

These may seem like extreme preventive services, but knowing these limits can help you financially. There are certain types of health care policies that do not include some or all of the expenses above in the calculation of your out-of-pocket maximum, so be sure to compare plans carefully. If you already have a health insurance company you work with, ask them what your coverage options are.

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Does a higher out-of-pocket maximum mean lower premiums?

As a rule of thumb, a health care plan with higher deductibles, co-pays, co-insurance, and an overall higher out-of-pocket maximum will come with a lower premium.

This type of coverage is typically known as a ‘catastrophic health care plan’ as you’re paying little in premium because you don’t really anticipate needing  heath care services. You essentially have health care coverage in place in case of emergencies. High-deductible health plans can end up being more expensive in the long run if end up having a lot of health care expenses throughout the year.

If it feels like you’re paying a large chunk of your own total healthcare costs even though you’re an insured person, you are. That’s the way the system works. Health insurance is designed to give us protection against very large medical bills.

Five thousand dollars may seem like a lot of money, but anyone who has become seriously ill or injured knows it can be just a drop in the bucket compared to what you could be on the hook for if uninsured and needing an office visit. This is especially true if you have any medical condition that requires continual preventive care and uses a hefty chunk of one’s income.

Contact an independent agent and/or get insurance quotes online if you’re currently without health insurance coverage. Medical care can be required at any point in time, so being safe rather than sorry can not only help you health wise, but also financially.

Shopping around for health insurance plans is incredibly useful. It’s the best way to ensure you receive the best coverage at the lowest price. There are various sorts of family and individual plans out there, so bear that in mind when you’re looking to settle on an insurance plan.

(photo: Mike Schmid)