Out-of-pocket maximum
Updated for plan year 2026
In plain terms
The out-of-pocket maximum is the most you have to pay for covered, in-network services in a plan year. Once your deductible, coinsurance, and copays add up to this limit, your plan pays 100 percent of covered care for the rest of the year. Monthly premiums don't count toward it, and neither do out-of-network charges or services the plan doesn't cover. Marketplace plans have a federal cap on this limit, set each year, with separate per-person and whole-family limits.
A plain example
Your out-of-pocket maximum is $8,000. You have surgery and a long recovery, paying your $3,000 deductible plus $5,000 in coinsurance over the year, $8,000 total. The moment you hit it, the plan covers every remaining covered, in-network service at 100 percent. A second surgery in December costs you nothing beyond your premium.
Why it matters
This is your worst-case number, the ceiling on what a bad health year can cost you short of going out of network. When you're comparing plans, it matters as much as the deductible: a plan with a scary deductible but a lower out-of-pocket maximum can protect you better in a true emergency.
A common point of confusion
Premiums never count toward the out-of-pocket maximum, and neither do charges for out-of-network care or non-covered services. Hitting the limit caps your covered, in-network costs, not every dollar you might spend on health care.