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member out of pocket maximum

mbr_oop_max
member·Updated Jun 23, 2026

Definition

ISO-11179 Definition

The maximum total amount a health plan member is required to pay out-of-pocket for covered services in a plan year, after which the insurance plan covers 100 percent of covered costs. Out-of-pocket maximums include deductibles, copays, and coinsurance but typically exclude premiums and out-of-network charges. Under the ACA, CMS sets annual out-of-pocket maximum limits for qualified health plans.

Medicare Advantage plans must comply with CMS-mandated out-of-pocket maximum requirements. Healthcare data teams build accumulator tracking pipelines that aggregate cost-sharing payments throughout the plan year to identify when members reach their out-of-pocket maximum and trigger full plan coverage in claims adjudication.

Standard Abbreviation

mbr_oop_max

Category

member

Production DDL — DIM_MEMBER

DIM_MEMBER.sql
CREATE OR REPLACE TABLE DIM_MEMBER (
    mbr_key           INTEGER        NOT NULL  -- surrogate key,
    mbr_id            VARCHAR(50)    NOT NULL  -- member identifier,
    mbr_first_nm      VARCHAR(100)             -- first name,
    mbr_last_nm       VARCHAR(100)             -- last name,
    mbr_birth_dt      DATE                     -- date of birth,
    mbr_gndr_cd       CHAR(1)                  -- gender code M/F/U,
    mbr_age           SMALLINT                 -- age in years,
    mbr_state_cd      CHAR(2)                  -- state code,
    mbr_zip_cd        VARCHAR(10)              -- zip code,
    mbr_elig_ind      BOOLEAN                  -- eligibility indicator,
    mbr_enrl_dt       DATE                     -- enrollment date,
    mbr_term_dt       DATE                     -- termination date,
    mbr_plan_cd       VARCHAR(20)              -- plan code,
    mbr_dual_elig_cd  VARCHAR(10)              -- dual eligibility code,
    load_dt           TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical member table. Convert to BigQuery or Databricks →

Why This Term Matters

Member and enrollment data governs who receives care and who pays for it — making it foundational to every downstream healthcare analytics workflow. Data engineers who understand member terminology build eligibility pipelines that prevent coverage gaps, correctly identify dual-eligible members, and support accurate risk adjustment submissions to CMS. Enrollment errors directly affect capitation payments and can trigger CMS corrective action plans.

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