Client Met the Out-of-Pocket Max? What to Check

Last reviewed: October 7, 2026.

Once a client has met their in-network out-of-pocket maximum, the plan generally pays 100% of covered in-network services for the rest of that benefit year, so therapy copays and coinsurance stop. Before you stop collecting, confirm with the payer which limit was met, as of what date, that outpatient therapy counts toward it, and when the benefit year ends.

When a client says “I hit my max”

Clients often hear it first, from their insurer or another provider, and tell the therapist. When a practice forwards that to us, we pause the client’s copay charges for a short, dated window while we verify the change with the payer, then either stop collecting for the rest of the year or resume. Pausing avoids charging someone who probably owes nothing; dating the pause keeps it from quietly turning into a permanent waiver if the client was mistaken.

HealthCare.gov describes the out-of-pocket maximum as the most a member pays for covered services in a plan year, after which the plan pays 100% of covered benefits. Every word in that sentence is something to verify.

What to confirm with the payer

1. Which limit: individual or family, and in-network or out-of-network. These are separate totals.

2. Remaining amount and as-of date. Benefit responses report “out-of-pocket remaining.” Record the number and the date you saw it.

3. That therapy is a covered, in-network service for this clinician under this plan. Meeting the limit does not make an out-of-network or non-covered service free.

4. The benefit year. Cost sharing returns when the next plan year starts, which is not always January.

Why the numbers lag

• Claims arrive out of order. Explanations of benefits for earlier sessions can come in after later ones and move what the client owes. A copay collected last week can turn out to be unnecessary once a pending claim pushes the client over the limit.

• Other providers count too. Cost sharing from the client’s other covered care can apply to the same total, so the limit can be met by claims you never see.

• Original Medicare has no cap. Clients on Original Medicare do not have an annual out-of-pocket limit; any limit comes from a supplement or a Medicare Advantage plan.

If you already collected

Compare each processed claim with what was collected. Where the claim shows no client responsibility, the payment becomes a credit. In one recent case a copay was still listed on a client whose cost share was actually zero; we set it to $0 in the EHR and the practice refunded the resulting credit to the client’s card. Fix the copay setting first, or the next session will be charged the same way.

To reset expectations when the year turns over, see what to recheck when a therapy deductible resets. For estimating cost share before the limit is reached, see how to estimate a therapy deductible, copay, or coinsurance.

Frequently Asked Questions

Should we stop charging copays as soon as the client tells us?

Pause them while you verify, with a set end date. Stop for the year only once the payer confirms the in-network limit was met.

Does the out-of-pocket maximum cover out-of-network therapy?

Not usually. In-network and out-of-network totals are tracked separately, and some plans have no out-of-network benefit at all.

Sources

• HealthCare.gov: Out-of-pocket maximum/limit

• HealthCare.gov: Plan year