Out-of-pocket maximum
The most you'll ever pay in a plan year for covered services, after which your insurance pays 100%.
Last reviewed August 23, 2026
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, so 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.
Many EOBs show your running progress toward the maximum. How to read an EOB covers where that figure appears.
Examples
Your plan has a $5,000 individual out-of-pocket max. After a hospitalization, you've paid $4,200 in deductible and coinsurance. On your next covered medical bill, your insurance pays 100% and 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.
Related terms
Deductible
The amount you pay out of pocket for covered services before your insurance begins to pay.
Premium
The recurring payment you make, monthly, quarterly, or annually, to maintain an insurance policy.
Copay
A fixed dollar amount you pay for a specific healthcare service, like $25 for a doctor visit, regardless of the total bill.
Coinsurance
The percentage of costs you share with your insurer after meeting your deductible, for example, you pay 20%, your insurer pays 80%.
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