An out-of-pocket maximum is the most you have to pay out of your own money for covered, in-network care in a plan year. Once your deductibles, copays, and coinsurance add up to that number, your health plan pays 100% of your covered benefits for the rest of the year. It is the financial safety net built into every Affordable Care Act-compliant plan.
Key Takeaways
- The out-of-pocket maximum is the yearly ceiling on what you pay for covered in-network care (HealthCare.gov[1]).
- The 2026 limit is no more than $10,600 for an individual and $21,200 for a family, rising to $12,000 and $24,000 in 2027.
- Deductibles, copays, and coinsurance count toward it; premiums, out-of-network care, and uncovered services do not.
- Family plans embed an individual limit so no one member can be charged more than the individual amount.
- Original Medicare has no out-of-pocket maximum, which is why Medigap policies exist.
What counts toward it, and what does not
The out-of-pocket maximum covers what you spend on deductibles, copays, and coinsurance for in-network covered services, as defined by HealthCare.gov[2].
Several things do not count toward it:
- Your monthly premium, the amount you pay for coverage whether or not you use care.
- Spending on services your plan does not cover.
- Out-of-network care and services.
- Amounts above the allowed amount a provider may charge, which is exactly why in-network care matters.
Understanding what is excluded matters, because a person can pay far more than the out-of-pocket maximum if they use out-of-network providers or uncovered services, and none of it is capped.
The 2026 and 2027 limits
There is a federal ceiling on how high a plan can set this amount. Per HealthCare.gov[1], for the 2026 plan year it is no more than $10,600 for an individual and $21,200 for a family. It rises to $12,000 for an individual and $24,000 for a family in 2027. A year earlier, in 2025, the limits were $9,200 and $18,400.
Those are maximums, not averages. Your actual out-of-pocket maximum is printed on your plan and is often lower, especially on costlier plan tiers. If you qualify for cost-sharing reductions on a Marketplace plan, the limit can drop substantially, to as low as a few thousand dollars for lower-income households.
Out-of-pocket maximum versus deductible
These two do different jobs and are easy to conflate.
The deductible is the amount you pay before your plan starts paying for most services. The out-of-pocket maximum is the total ceiling on everything you pay all year. The deductible is a mile marker along the way; the out-of-pocket maximum is the finish line.
In practice, the deductible is almost always smaller than the out-of-pocket maximum. You pay your deductible first, then keep paying copays and coinsurance, and only when the sum reaches the out-of-pocket maximum does the plan take over at 100%.
A concrete example: a plan with a $3,000 deductible and 20% coinsurance. On a year with $12,000 of allowed costs, you pay the $3,000 deductible plus 20% of the remaining $9,000, or $1,800, for $4,800, and you have not even approached the out-of-pocket maximum (HealthCare.gov[3]). The maximum only becomes relevant in an expensive year.
How family plans work
On a family plan, there are two limits: a per-person individual limit and a family limit. Since 2016, federal rules require family plans to embed an individual out-of-pocket maximum so that no single family member can be charged more than the individual limit, even if the family as a whole has not reached the family amount (HealthCare.gov[1]). In 2026 that embedded individual limit is $10,600.
A plan can be structured two ways, and the distinction matters if more than one family member needs care:
- Embedded: each person has their own individual limit. Once one person hits $10,600, the plan pays 100% for that person's covered care, while the rest of the family continues toward the family cap.
- Aggregate: the family shares one pool, and no one gets full coverage until the combined family spending reaches the family limit.
Embedded limits are the more common and more protective structure today, because the federal rule mandates the individual cap within family coverage regardless of the family total.
The Medicare exception
Original Medicare is the major contrast. Unlike ACA-compliant private plans, Original Medicare has no out-of-pocket maximum at all. There is no cap on what a beneficiary can pay in a year, which is why Medicare Supplement (Medigap) policies exist to cover the coinsurance and deductibles that would otherwise be open-ended. The Urban Institute[4] documents this gap directly, noting that Part B carries a $283 deductible and 20% coinsurance in 2026 with no cap on total cost-sharing.
Why it matters for planning
The out-of-pocket maximum is the number to use when you are weighing a plan or bracing for an expensive year. It tells you the worst-case cost for covered care, which makes it useful for comparing a high-premium, low-limit plan against a low-premium, high-limit plan. It also resets every plan year, so a plan that fits you now may not fit after the limits reset in January.
Frequently asked questions
What is the difference between a deductible and an out-of-pocket maximum? The deductible is what you pay before insurance starts paying. The out-of-pocket maximum is the most you pay all year before insurance covers 100% (HealthCare.gov[1]).
What is the out-of-pocket maximum for 2026? No more than $10,600 for an individual and $21,200 for a family, per HealthCare.gov[1]. It rises to $12,000 and $24,000 in 2027.
Do copays and coinsurance count toward the out-of-pocket maximum? Yes. Deductibles, copays, and coinsurance for covered in-network care all count. Premiums, out-of-network care, and uncovered services do not (HealthCare.gov[2]).
What happens when I reach my out-of-pocket maximum? Your plan pays 100% of covered in-network services for the rest of the plan year.
Does the out-of-pocket maximum reset? Yes, it resets each plan year, usually on January 1.
Does my premium count toward the out-of-pocket maximum? No. The premium is separate, and you pay it whether or not you use care (HealthCare.gov[2]).
What is an embedded out-of-pocket maximum? A per-person limit inside a family plan, so that no single family member pays more than the individual limit even before the family total is reached (HealthCare.gov[1]).
Does Medicare have an out-of-pocket maximum? Original Medicare does not, which is why many people buy a Medigap policy to cover open-ended coinsurance (Urban Institute[4]).
Does out-of-network care count toward my out-of-pocket maximum? Generally no. Only covered in-network care counts, so out-of-network care can cost far more than the maximum (HealthCare.gov[2]).
This is patient education, not financial or legal advice. Figures are tied to their primary sources and year, and change every plan year. Reviewed October 3, 2026.