Out-of-Pocket Maximum
Plain English
The out-of-pocket maximum is the most you'll pay in a year for covered, in-network health care. What you pay in deductibles, copays and coinsurance adds up toward it. Once you reach it, your plan pays the full cost of covered in-network care until the plan year ends. Your monthly premiums don't count toward it.
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On this page
Definition
The out-of-pocket maximum, or out-of-pocket limit, is the most a health plan member has to pay for covered, in-network services in a plan year. Deductibles, copayments and coinsurance count toward it; once it is reached, the plan pays 100% of the costs of covered in-network benefits for the rest of the plan year. Premiums, non-covered services and out-of-network care generally don't count toward it.
Why It Matters
It's the number that tells you your worst case. A plan with a low premium but a high out-of-pocket maximum can cost far more in a year with a surgery or a serious diagnosis. It's also why staying in network matters: out-of-network costs may not count toward the limit at all.
Real-World Example
Imagine a plan with a $3,000 deductible, 20% coinsurance and a $6,850 out-of-pocket maximum, the figures in HealthCare.gov's example. A year of cancer treatment runs to $60,000 in allowed in-network costs. You pay the $3,000 deductible, then 20% coinsurance until your total reaches $6,850. After that, the plan pays the covered in-network costs in full for the rest of the year, though you keep paying your premiums.
Common Misconceptions
- Premiums count toward the out-of-pocket maximum. They don't.
- The limit applies to any care. It generally covers in-network, covered services; out-of-network care and non-covered services usually don't count.
- Out-of-pocket maximum and deductible are the same. The deductible is what you pay before the plan starts paying; the maximum caps everything you pay in a year.
Key Takeaways
- HealthCare.gov: the out-of-pocket maximum is "the most you have to pay for covered services in a plan year."
- Deductibles, copays and coinsurance for in-network care count toward it.
- For 2026 Marketplace plans, the limit is no more than $10,600 for an individual or $21,200 for a family.
- Premiums, non-covered services, out-of-network care and charges above the allowed amount don't count.
Frequently Asked Questions
What is an out-of-pocket maximum?
The most you have to pay for covered, in-network health care in a plan year. After you reach it, your plan pays 100% of covered in-network costs.
What counts toward the out-of-pocket maximum?
Deductibles, copayments and coinsurance for covered in-network care. Premiums, services your plan doesn't cover, out-of-network care and costs above the allowed amount don't.
What is the out-of-pocket maximum for 2026?
For Marketplace plans, HealthCare.gov lists no more than $10,600 for an individual or $21,200 for a family in 2026. Your plan's limit may be lower.
What's the difference between a deductible and an out-of-pocket maximum?
The deductible is what you pay before the plan starts sharing costs. The out-of-pocket maximum caps the total you pay in the year, including the deductible.
Does the out-of-pocket maximum reset?
Yes, at the start of each plan year, along with the deductible.
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The factual claims on this page were checked against these sources. Rules and figures change, so check the source itself if you need to confirm the current version.
- healthcare.govOut-of-pocket maximum/limit - Glossary · HealthCare.gov (U.S. Centers for Medicare & Medicaid Services)
- healthcare.govCoinsurance - Glossary · HealthCare.gov (U.S. Centers for Medicare & Medicaid Services)
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