Speak with a Covered California certified agent! Call (888) 413-3164 or Shop Online Now

Shop and Compare

California Health Insurance Plans and Rates

It's easy. Just enter your zip code.

Covered California Q&A

Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.


What is Maximum-Out-Of-Pocket Based On?

By on | No Comments

Question: Does the Maximum Out-of-Pocket of $6,350 include total cost to the consumer for any given care or is it limited to the insurance company's "negotiated rate" for a given treatment? In other words is the patient stuck with the costs above and beyond the negotiated rate and if so, will that cost go towards the "maximum out-of-pocket" or will it not?

Answer: The out-of-pocket maximum of $6,350 for covered expenses in a calendar year is based on the negotiated or contract rate. There is no patient responsibility beyond the contract rate for in-network expenses. Out-of-Network coverage has a higher out-of-pocket maximum and the patient is responsible for charges beyond the contract rate.

Leave a comment

Do You Have California Health Insurance Questions?

Ask An Expert

View Previous Questions
Call Us at (888) 413-3164


© 2019 California Health Benefit Advisers, LLC
Home / About / Start Shopping / Ask a Question

“Covered California,” “California Health Benefit Exchange”, and the Covered California Logo are registered trademarks or service marks of Covered California, in the United States. This web site is owned and maintained by California Health Benefit Advisers, LLC, which is solely responsible for its content.