In what situation might a policyholder reach their out-of-pocket maximum?

A policyholder reaches their out-of-pocket maximum primarily by incurring high medical expenses for covered services. The out-of-pocket maximum is the most a policyholder will pay for covered health care services in a plan year. Once this limit is reached, the insurance company pays 100% of covered services, meaning that any additional costs for covered treatments or procedures are no longer the policyholder's responsibility.

In this scenario, when a policyholder faces a significant amount of medical expenses—such as hospitalization, surgeries, or other necessary treatments—they effectively accumulate costs that contribute toward their out-of-pocket maximum. This design is intended to protect individuals from catastrophic financial burdens in the event of serious health issues or accidents.

Other situations mentioned, such as failing to pay monthly premiums, using only out-of-network providers, or not utilizing any medical services, do not contribute to reaching the out-of-pocket maximum. Not paying premiums can lead to a loss of coverage altogether, using out-of-network providers may incur higher costs without contributing to the out-of-pocket limit, and not using medical services would mean that there are no expenses to count toward the maximum at all.