Maximum-Out-of-Pocket Information

To find your maximum-out-of-pocket limits, sign in to your account, select Benefits from the left navigation menu, and view your Summary of Benefits under Health Plan Documents. You must register for an account on OhioHealthyPlans.com to access these account features.

Most OhioHealthy plans limit the dollar amount you will have to pay during your plan year. This maximum-out-of-pocket amount or limit is the total amount you and any dependents will pay out of pocket for copayments, coinsurance and deductibles during a plan year. Your specific maximum amount is determined by your plan benefits and can be found on your OhioHealthy Fact Sheet, or with the Schedule of Benefits on your Evidence of Coverage or Certificate of Insurance.

Depending on your health plan, copayments, coinsurance and deductibles you pay for certain services may count toward your maximum out-of-pocket amount. Your specific plan may have separate maximum amounts for in-network services and out-of-network services.

Some out-of-pocket expenses do not count toward your maximum amount. A list of these health services can be found on your Fact Sheet or Schedule of Benefits. For those services, you will still have to pay your copayments, coinsurance and deductibles even after you have reached your maximum out-of-pocket amount.

When you have reached your maximum out-of-pocket amount, no further payments will be required for the plan year except for those services that do not apply toward this amount. OhioHealthy maintains a record of your payments and will send you a letter within 30 days of reaching your out-of-pocket limit. Present this letter to your physician when obtaining medical care to avoid further charges.

If you have any questions or believe you are entitled to a refund for an overpayment against your maximum amount, contact a Member Advocate at the number on the back of your member ID card.