Plain version: the deductible, coinsurance and copayments are the insured's share of covered care, and the maximum out-of-pocket expense is the ceiling on that share. Example: a $1,500 deductible, then 20% coinsurance, with an $8,000 out-of-pocket maximum. For an in-network hospital stay with a $6,500 allowed amount and nothing paid yet this year, the insured pays $1,500 + 20% of $5,000 ($1,000) = $2,500, which is under the maximum.
California's annual out-of-pocket limit on essential health benefits (Ins. Code §10112.28):
It applies to copayments, coinsurance, deductibles and any other form of cost sharing for essential health benefits. Premiums never count; they are the price of coverage, not cost sharing.
An individual within a family may not have a limit greater than the limit for individual coverage. Once one family member reaches it, that person's cost sharing stops, even if the family total is not met.
The limit must include out-of-network emergency care.
Preventive care with no cost sharing: nongrandfathered policies must cover services that have an A or B rating from the U.S. Preventive Services Task Force, with no cost-sharing requirement (Ins. Code §10112.2). No deductible, coinsurance or copayment applies, even if the insured has not met the deductible.
Coordination of benefits: when a person is covered by two group plans that both have a coordination of benefits provision, the primary plan pays first and the secondary plan pays at most the remainder, so the insured does not collect more than 100% of covered expenses (Ins. Code §10270.98). Example: $2,000 of covered expenses and a $1,500 primary payment leave at most $500 for the secondary plan.
Elimination period, one more time: a period after a loss begins during which no benefits are payable, so it works like a deductible measured in time rather than dollars. Do not confuse it with the grace period, which is extra time to pay a premium while coverage continues (next page), or the maximum benefit period, which is how long benefits can be paid once they start.