What Counts Toward My Out-of-Pocket Maximum in North Carolina, and What Doesn’t?

Learn what payments count toward your out-of-pocket maximum in North Carolina health insurance plans, and what costs don’t. Billy Jordan of The Jordan Insurance Agency breaks down the rules to help you avoid surprises.

In this episode

• What payments count toward your out-of-pocket maximum in North Carolina
• Which costs—like premiums and out-of-network bills—do not count
• How individual and family out-of-pocket limits work for North Carolina plans

Source: Out-of-pocket maximum/limit (healthcare.gov)

Billy Jordan is a licensed insurance agent (NPN 8699876) with The Jordan Insurance Agency, based in Charlotte, North Carolina. Voices in this episode are AI-generated, including Billy's, from a script reviewed and approved by Billy Jordan, a licensed insurance agent. General education only, not advice for your specific situation.

Tanya (AI host): What exactly counts toward my out-of-pocket maximum, and what doesn’t? I’ve heard that hitting that limit means your insurance pays everything after, but it sounds like there are exceptions—so let’s break it down.

Tanya (AI host): Welcome to Smart Coverage. Real Advice., the insurance podcast from The Jordan Insurance Agency. I'm Tanya, your host, and I'm here with Billy Jordan, a licensed insurance agent and the president of The Jordan Insurance Agency.

Billy Jordan: Hey Tanya, always happy to be here. This is a great topic—out-of-pocket maximums can be confusing, but understanding them really helps folks avoid surprises when it comes to health care costs.

Tanya (AI host): So let’s start simple. What is an out-of-pocket maximum, and what happens when I reach it?

Billy Jordan: The out-of-pocket maximum is the most you’ll have to pay in a year for covered health care services. Once you reach that dollar amount—by paying deductibles, copays, and coinsurance for in-network covered services—your health plan pays one hundred percent of the costs for covered benefits for the rest of the year.

Tanya (AI host): So after I reach that limit, I don’t pay anything else for those in-network covered services?

Billy Jordan: That’s right. If you hit your out-of-pocket maximum, the insurance company pays the full cost of any more covered, in-network care you need for the rest of your plan year. But it’s important to remember, this only applies to services your plan covers and that are in-network.

Tanya (AI host): Can you give me an example of how that might play out for someone here in North Carolina?

Billy Jordan: Sure. Let’s say you have a health plan and you end up needing a lot of care early in the year—maybe surgery and follow-up visits. Between your deductible, copays, and coinsurance, you pay enough out of your own pocket for those in-network services to reach your plan’s out-of-pocket maximum. After that, if you need more covered care—like physical therapy, prescriptions, or doctor visits—the insurance company pays for those, as long as they’re covered and in-network.

Tanya (AI host): That’s a relief for folks who have a rough year health-wise. But what’s a common mistake people make about this?

Billy Jordan: A lot of people think once they hit that out-of-pocket max, every health care cost is covered. But premiums, out-of-network bills, and services your plan doesn’t cover don’t count. That can catch people off guard.

Tanya (AI host): Okay, so what exactly counts toward the out-of-pocket maximum? Is it really just the deductible, copays, and coinsurance?

Billy Jordan: Yes, according to healthcare.gov, the only things that count toward the out-of-pocket maximum are what you pay for deductibles, copayments, and coinsurance for in-network covered services. That’s it. Those three are the biggies.

Tanya (AI host): So if I have a high deductible and I’m paying copays at the doctor, all of that is chipping away at my out-of-pocket max?

Billy Jordan: Exactly. Every time you pay a copay for a covered in-network visit, or you pay coinsurance after your deductible, that money goes toward your yearly out-of-pocket max. Once you hit that limit, you stop paying for those things.

Tanya (AI host): But what about my monthly premium? Does that count toward the out-of-pocket maximum?

Billy Jordan: No, and that’s a really important point. Your monthly premium—the amount you pay each month just to keep your coverage active—does not count toward your out-of-pocket maximum. Even if you’re paying a high premium, that’s separate from what you pay for actual care.

Tanya (AI host): So that’s a cost I’ll have to budget for all year, no matter what?

Billy Jordan: That’s right. Premiums are like your membership fee for having insurance. The out-of-pocket maximum is about what you pay when you actually use your coverage.

Tanya (AI host): Are there any other things that don’t count toward the out-of-pocket maximum?

Billy Jordan: Yes, a few. Anything you spend on services that your plan doesn’t cover won’t count. Also, out-of-network care usually doesn’t count unless your plan specifically allows it. And if you go to an out-of-network provider who charges more than what your plan allows, the extra amount you pay above that allowed amount doesn’t count either.

Tanya (AI host): So let’s say I go to a doctor who isn’t in my network. Even if I pay a lot out of pocket, that won’t help me reach my in-network out-of-pocket max?

Billy Jordan: Exactly. That’s a common trip-up. Folks think all their health spending is adding up, but only in-network, covered expenses count for the out-of-pocket maximum. Out-of-network bills and uncovered services are outside that limit.

Tanya (AI host): How about for families—does the out-of-pocket max work the same way?

Billy Jordan: Yes, there’s a separate out-of-pocket maximum for individuals and for families. According to healthcare.gov, in twenty twenty-six, no Marketplace plan can have an out-of-pocket maximum higher than ten thousand six hundred dollars for an individual, or twenty-one thousand two hundred for a family. In twenty twenty-seven, the limits are twelve thousand dollars for an individual and twenty-four thousand dollars for a family. Once your family as a whole hits that limit for in-network covered services, the plan pays everything for the rest of the year for covered care.

Tanya (AI host): So if one person in the family has big medical bills, they could reach the individual limit, and if the whole family’s expenses add up, you could hit the family limit?

Billy Jordan: Exactly. It’s a safety net so families aren’t stuck with unlimited costs in a tough year.

Tanya (AI host): Three things to remember. One, only your deductible, copays, and coinsurance for in-network covered services count toward your out-of-pocket maximum. Two, premiums, out-of-network costs, and uncovered services don’t count. Three, families have both individual and family out-of-pocket limits, and it pays to know both.

Tanya (AI host): For a personalized look at your situation, book a free thirty-minute chat with Billy and his team at thejordaninsuranceagency.com/podcast.

Billy Jordan: I'm Billy Jordan with The Jordan Insurance Agency. Until next time, take care.

Tanya (AI host): Thanks for listening to Smart Coverage. Real Advice. from The Jordan Insurance Agency.