Out-of-Pocket Maximum

Provider Type

  • Physicians
  • Participating Physician Groups (PPG) 
    (does not apply to HSP)
  • Hospitals
  • Ancillary

Health Net members may be required to pay copayments for covered professional or hospital services. Copayments are limited to an established annual amount, referred to as the out-of-pocket maximum (OOPM), which is specified in the member's Evidence of Coverage (EOC ). No further copayments for covered services may be imposed on a Health Net member once the OOPM has been met for the calendar year. OOPM amounts are subject to change annually.

Aggregate deductible/OOPM plans: Many plans have a member-level OOPM, two-party OOPM and a family-level maximum for the entire family. No individual member has to pay a greater copayment amount than the amount required for a single-party contract in a calendar year. All copayments paid by all members in a family are added together to reach the applicable family OOPM (PDF).