What happens once a person reaches their out-of-pocket maximum?

Once a person reaches their out-of-pocket maximum, their insurance coverage will pay for 100% of eligible medical expenses for the remainder of the plan year. This mechanism is designed to protect individuals from excessive costs associated with healthcare services. After reaching this limit, the insured will not have to pay any more deductibles, copayments, or coinsurance for covered services.

This provision encourages individuals to seek necessary medical care without the burden of additional financial costs after a substantial outlay in medical expenses. It's important to understand that the out-of-pocket maximum is an accumulated amount reflecting what the insured has already spent in a given year, reinforcing the plan's role in safeguarding financial health against unexpected medical costs.

By contrast, the other options do not accurately reflect the purpose or outcome of reaching the out-of-pocket maximum. For example, a person does not stop needing coverage; nor do they receive lower premiums after this milestone. Changing insurance policies immediately is not a requirement tied to the out-of-pocket maximum and would involve different considerations entirely.