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Out-of-Pocket Maximum

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • 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).

Exclusions and Limitations

The terms of a member's Evidence of Coverage (EOC) lists in detail out-of-pocket costs that do not apply to the out-of-pocket maximum (OOPM). The following listing summarizes some costs that do not apply toward the OOPM amount:

  • Expenses incurred for non-covered services
  • Eyewear expenses
  • Copayments for prescription medications. May not apply to some plans; refer to the Schedule of Benefits for specific information.

Some plans exclude expenses incurred for specific covered services. These exclusions are noted on the benefit plan chart in the Schedule of Benefits.

General Filing Requirements

When a member reaches the specified out-of-pocket maximum (OOPM) amount for any calendar or plan year, a claim can be submitted to Health Net. All claims must be submitted on a Health Net Out-of-Pocket Maximum Notification Form (CLM 114) (front of form (PDF), back of form (PDF). Once Health Net receives the claim form and establishes that the OOPM has been met, the member is released from any further copayment liability for that calendar or plan year. OOPM claims are reimbursable on a calendar or plan year basis only. Instruct members who wish to claim their OOPM for a particular year to contact the Health Net Member Services Department . Members should also refer to their Evidence of Coverage (EOC) to obtain their OOPM amount.

Participating physician groups (PPGs) or primary care physicians (PCPs) may request a Health Net Out-of-Pocket Maximum Notification Form (CLM 114) by contacting the Health Net Provider Services Center.

The subscriber is responsible for keeping a record of all copayments paid by all members on the plan. Proof of paid copayments include receipts and cancelled checks. Members mail the Health Net Out-of-Pocket Maximum Notification Form (CLM 114) and copies of all receipts and cancelled checks to the Health Net Claims Department.

Settlement of OOPM Claims

On receipt of a Health Net Out-of-Pocket Maximum (OOPM) Notification Form (CLM 114) (front of form (PDF), back of form (PDF) and copies of all receipts and cancelled checks, Health Net:

  • Checks for eligibility
  • Determines whether the services the member received were covered benefits
  • Verifies receipts or cancelled checks
  • Adds all copayments paid to verify that they equal the annual OOPM

When the OOPM has been satisfied, Health Net sends a letter (PDF) to the subscriber stating that no further copayments will be collected for the remainder of the calendar year. Health Net sends a copy of the letter (PDF) to the member's participating physician group (PPG) or primary care physician (PCP) and Health Net retains a copy in its files. If the contract changes during the year, additional copayments may be collected, depending on the conditions in the new contract.

If the amount of copayments paid by the subscriber exceeds the OOPM, the Health Net Claims Department takes the following steps:

  • For shared-risk services: Health Net reimburses the subscriber (proof that payment has been made required) for copayments made on shared-risk services and out-of-area claims. For the remainder of the calendar year, the shared-risk fund covers the required copayment for inpatient hospital charges on some plans, or the copayment required by the majority of plans for emergency room or urgent care center treatment within the selected PPG and PCP service area. A letter (PDF) is sent to the PPG or PCP administrator, with a copy retained on file at Health Net.
  • For capitation and insured services: Health Net sends a letter (PDF) to the member's PPG or PCP to notify them that the member is due reimbursement. For the remainder of the calendar year, all professional services are covered by capitation and no additional copayments may be collected by the PPG or PCP. The copayment amounts are not deducted from professional stop loss payments if the PPG or PCP states on the professional stop loss claim that the member has reached the OOPM.
Last Updated: 07/01/2024