Out-of-Pocket Maximum Explained

The out-of-pocket maximum is the most you'll spend on covered in-network healthcare in a single plan year. Once you hit that number, your insurance pays 100% for the rest of the year. It's your financial safety net against catastrophic medical costs.

2026 Limits

For 2026, ACA-compliant plans cap the out-of-pocket maximum at $10,150 for individual coverage and $20,300 for family coverage (CMS). HDHPs have a lower cap: $8,500 for individuals and $17,000 for families, set by the IRS for HSA eligibility. These numbers have climbed steadily. In 2014, the first year of ACA plans, the individual cap was $6,350.

What Counts Toward It

Your deductible, copays, and coinsurance all count toward the out-of-pocket maximum. Every dollar you spend on covered in-network services adds up. Once the total hits the cap, you're done paying for the year.

What Doesn't Count

Your monthly premiums do not count toward the out-of-pocket max. Neither do out-of-network charges on most plans. Balance-billed amounts and services not covered by your plan are also excluded. This means that even after hitting the max, you could still owe money for out-of-network care or uncovered services.

Why It Matters More Than You Think

If you're expecting a major medical event (surgery, cancer treatment, having a baby), the out-of-pocket max is the number that matters most. A plan with 40% coinsurance sounds expensive, but if the out-of-pocket max is $8,500, that's your actual worst case for in-network care. Once you're there, everything else is covered.

When comparing plans, look at the out-of-pocket max alongside the premium. Sometimes a plan with a slightly higher premium has a much lower out-of-pocket max, which could save you thousands if you end up needing serious care.