10 health services to consider if you’ve met your out-of-pocket maximum

At some point, your health care bills in any given year may be high enough that they’re over your insurance’s out-of-pocket maximum.

The out-of-pocket maximum is the most you’ll have to pay for covered health expenses in one calendar year. Once you reach the out-of-pocket maximum, any covered health care expenses you incur after that are free through Dec. 31 of that year. Yes, free.

That’s why when you reach the out-of-pocket maximum, it’s a good time to get certain procedures, blood tests or surgeries that may not be urgent but still necessary.

Out-of-pocket maximum, a green light for spending

If you’re at or over your out-of-pocket maximum, it’s as if the green light is lit on spending for health care until the end of the year.

You might see a podiatrist about the toe fungus you keep hoping will go away on its own. You might get a hernia surgery to eliminate the nagging off-and-on pain in your middle or meet with a dietitian to try to lose weight.

Know your out-of-pocket maximum

Remember that all procedures or appointments have to be considered necessary for your health. That means the tab for a tummy tuck or botox treatments for wrinkles is on you.

How much your out-of-pocket maximum is depends on your insurance policy. That’s a good figure to know every year because it changes.

In 2024, the out-of-pocket maximum is $9,450 for individuals and $18,900 for families for health insurance policies sold on the Health Insurance Marketplace, which the federal government runs. Some insurance policies have a higher out-of-pocket maximum; some, a lower one.

Health care deductible vs. out-of-pocket maximum

Even if you don’t reach the out-of-pocket maximum, your health care expenses might exceed your insurance policy’s deductible.

A deductible is the amount of money you pay for health care before the insurance company starts paying for all or a significant share of the cost of covered expenses in a given year. That may be closer to around $2,000, depending on your policy.

Once your health care costs go over the deductible amount, your share of the costs of future covered expenses goes down considerably compared to what you’d pay before your deductible is met.

So even if you don’t meet your out-of-pocket maximum for the year, if you’ve met your deductible, tests or surgeries might cost you a lot less.

Health services to take advantage of

If you meet the annual deductible amount or out-of-pocket maximum, take advantage of having expensive immunizations or medications filled. You can ask your doctor to prescribe a 90-day or six-month supply so you that have enough medicine that will carry you into the next year.

You might also consider:

1 A dermatologist for a skin cancer check, acne or another issue

2 Surgeries:

• Joint replacement
• Hernia
• Toe problems such as bunions or another condition
• Cataract removal

3 Imaging:

• An MRI for a longtime sports injury
• A bone density scan after menopause

4 Tests for:

• Blood glucose levels (A1C or fasting glucose)
• Anemia
• Food allergies

5 Physical therapy for an injury

6 Sports medicine — steroid or another treatment for joint pain relief

7 Replacing your old medical equipment:

• Continuous positive airway pressure (CPAP) machine for sleep apnea
• Glucose monitor
• Hospital bed
• Insulin pump
• Knee braces
• Compression stockings
• Wheelchair

8 Mental health

• Counseling sessions
• An evaluation for ADHD, dyslexia, autism or another condition

9 Preventive tests

• Colonoscopy
• Mammogram
• Pap smear
• Testing for human papillomavirus (HPV) or other sexually transmitted infections

10 Dietitian sessions for weight loss, lowering your blood sugar or restoring lost muscle mass

It’s important to know when you’ve met your deductible and/or your out-of-pocket maximum. Many health insurance companies send regular updates tallying your health care expenses in the year so far. If you don’t get those, contact your health insurance company. You don’t want to get to the end of November and try to schedule a lot of procedures and appointments for the last month of the year.

Health care is expensive. You can keep costs down by staying aware of how close your expenses are to your annual deductible and out-of-pocket maximum and knowing when to get a procedure or book an appointment and when you can wait a few months.