Out-of-pocket maximum
The most you'll ever pay in a plan year for covered services — after which your insurance pays 100%.
Definition
The out-of-pocket maximum (also called the out-of-pocket limit) is the most you will pay in a single plan year for covered healthcare services. Once you reach this limit, your insurance company pays 100% of covered services for the rest of the year — no more deductibles, copays, or coinsurance.
The out-of-pocket maximum is a critical financial protection that caps your exposure if you have a major health event.
What counts toward your out-of-pocket max: Deductibles, copays, and coinsurance for covered in-network services. Specifics vary by plan — check your Summary of Benefits.
What usually doesn't count: Premiums, out-of-network costs (often have a separate limit or no limit), non-covered services, costs above the plan's allowed amount.
For 2026, ACA-compliant plans have a maximum limit of $9,450 for individuals and $18,900 for families.
The out-of-pocket max is one of the most important numbers to understand when comparing health plans — especially if you or a family member have significant health needs.
Examples
Your plan has a $5,000 individual out-of-pocket max. After a hospitalization, you've paid $4,200 in deductible and coinsurance. Your next covered medical bill — your insurance pays 100%, you pay nothing.
Your family out-of-pocket max is $10,000. Two family members hit their individual limits of $5,000 each. All covered care for the entire family is now free for the rest of the year.
When choosing between a PPO ($500 premium, $3,000 OOP max) and HDHP ($300 premium, $6,500 OOP max), the HDHP saves $2,400/year in premiums — but exposes you to $3,500 more in worst-case costs.
Frequently asked questions
Is the out-of-pocket maximum the same as the deductible?
No. The deductible is what you pay before insurance starts sharing costs. The out-of-pocket maximum is the total cap on everything you'll pay in a year (including deductible, copays, and coinsurance combined).
Does the out-of-pocket max reset every year?
Yes — for health insurance, the out-of-pocket maximum resets on January 1 (or your plan anniversary date).
Do out-of-network costs count toward my out-of-pocket max?
Usually not, or they count toward a separate (higher) out-of-network limit. Using in-network providers is critical to getting the benefit of your out-of-pocket maximum protection.
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