Out-of-pocket maximum
Clinical reviewer: Elena Gizzi, MSN, RN · Last checked September 16, 2026
What is an out-of-pocket maximum?
Out-of-pocket maximum is the most you have to pay for covered services in a plan year before your health plan starts covering 100% of the costs of covered benefits. It includes deductibles, copayments and coinsurance for in-network care, but not everything you spend on health care during the year.
What counts toward your out-of-pocket maximum?
Once you have paid your deductible, your copayments and coinsurance for in-network covered services all count toward this limit [1]. It builds on your deductible, the amount you pay before your plan starts to pay its share [2]. After you reach the maximum, your plan pays 100% of the costs of covered, in-network benefits for the rest of the plan year [1].
What doesn't count, and how high can it be?
Your monthly premiums, costs for services your plan doesn't cover, out-of-network care, and any amount above what your plan considers an allowed charge do not count toward the maximum [1]. Marketplace plans cap it at $10,600 for an individual or $21,200 for a family in 2026, rising to $12,000 or $24,000 in 2027 [1]. Your specific plan can set the limit lower than the cap.
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This entry is for education and is not medical advice. Talk with a licensed clinician about your own situation before starting, stopping, or changing any treatment.
