An out-of-pocket maximum is generally the most you must pay during a plan year for covered health care expenses that count toward your plan’s limit. Deductibles, copayments, and coinsurance for qualifying in-network care commonly count toward the maximum. After you reach the applicable limit, a Marketplace plan pays 100% of covered in-network benefits subject to the limit for the rest of the plan year. Monthly premiums, non-covered services, and many out-of-network expenses do not count toward the maximum.
Key Takeaways
- The out-of-pocket maximum limits how much qualifying cost sharing you pay during a plan year for covered services subject to the limit.
- Deductibles, copayments, and coinsurance for covered in-network care generally count toward a Marketplace plan’s limit.
- Monthly insurance premiums do not count toward the out-of-pocket maximum.
- For 2026, a Marketplace plan’s out-of-pocket limit cannot exceed $10,600 for an individual or $21,200 for a family.
- A plan can have an out-of-pocket maximum below the federal ceiling, so compare the actual limit shown in each plan’s documents.
How Does an Out-of-Pocket Maximum Work?
Health insurance typically requires you to share some of the cost of covered medical care. Depending on the plan, you may pay deductibles, copayments, or coinsurance as you receive services.
The out-of-pocket maximum places an annual ceiling on qualifying cost sharing.
For a Marketplace plan, once qualifying deductibles, copayments, and coinsurance for covered in-network services reach the plan’s out-of-pocket maximum, the plan pays 100% of covered benefits subject to that limit for the remainder of the plan year.
Think of the out-of-pocket maximum as a financial safety limit for qualifying covered care. It does not eliminate every possible health care expense, but it can protect you from unlimited cost sharing for covered in-network services during a plan year.
Out-of-Pocket Maximum vs. Deductible
The deductible and out-of-pocket maximum are related, but they are not the same thing.
The deductible is the amount you generally pay for certain covered services before the health plan begins paying its applicable share.
The out-of-pocket maximum is a higher ceiling that limits qualifying cost sharing during the plan year.
| Feature | Deductible | Out-of-Pocket Maximum |
|---|---|---|
| Basic purpose | Determines when the plan begins sharing the cost of certain services. | Limits qualifying annual cost sharing. |
| What happens after reaching it? | You may still pay copayments or coinsurance. | The plan generally pays 100% of applicable covered in-network benefits for the rest of the plan year. |
| Premium included? | No. | No. |
For example, you might meet a $2,000 deductible early in the year but continue paying copayments and coinsurance until your qualifying spending reaches a $6,500 out-of-pocket maximum.
What Counts Toward an Out-of-Pocket Maximum?
For Marketplace plans, qualifying amounts generally include what you spend on deductibles, copayments, and coinsurance for covered in-network care and services.
- Deductible payments: qualifying amounts you pay before broader plan cost sharing begins.
- Copayments: fixed amounts charged for applicable covered services.
- Coinsurance: your percentage share of applicable covered health care costs.
Exactly how a particular expense is credited toward the limit depends on the plan and applicable rules. Your plan’s Summary of Benefits and Coverage and other policy documents should explain the cost-sharing structure.
What Does Not Count Toward the Out-of-Pocket Maximum?
One of the biggest mistakes consumers make is assuming every dollar spent on health care counts toward the annual limit.
For Marketplace plans, the out-of-pocket maximum generally does not include:
- Monthly premiums: the amount you pay to keep coverage active.
- Services the plan does not cover: if a service is excluded, what you pay for it generally does not count.
- Out-of-network care: expenses for providers outside the network generally do not count toward a Marketplace plan’s in-network limit.
- Amounts above the plan’s allowed charge: amounts a provider may bill above the insurer’s allowed amount generally do not count.
Reaching your out-of-pocket maximum does not mean every future medical bill for the year is automatically $0. You can still owe premiums and potentially pay for excluded or otherwise non-qualifying expenses.
What Is the 2026 Out-of-Pocket Maximum?
For the 2026 plan year, HealthCare.gov states that a Marketplace plan’s out-of-pocket limit cannot be higher than:
| 2026 Marketplace Coverage | Maximum Federal Out-of-Pocket Limit |
|---|---|
| Individual coverage | $10,600 |
| Family coverage | $21,200 |
These figures are federal ceilings for Marketplace plans, not amounts that every enrollee must spend.
A particular health plan can have a lower out-of-pocket maximum. For example, one 2026 plan might have an individual limit of $7,500 while another might use a higher amount within the federal limit.
A lower out-of-pocket maximum can be valuable if you expect substantial medical care. However, compare the premium and other plan features too, because plans with lower cost sharing can have higher monthly premiums.
A Practical Example of How the Limit Works
Consider a hypothetical individual health plan with the following numbers. These amounts are examples only and are not national averages.
Deductible: $2,000
Coinsurance after deductible: 20%
Out-of-pocket maximum: $7,000
Suppose the member has significant covered in-network medical expenses during the year.
- The member first pays qualifying expenses toward the $2,000 deductible.
- After satisfying the deductible, the member continues paying applicable copayments or 20% coinsurance.
- Those qualifying payments continue accumulating toward the $7,000 out-of-pocket maximum.
- Once qualifying spending reaches $7,000, the plan generally pays 100% of applicable covered in-network benefits for the rest of that plan year.
The member would still need to keep paying the monthly premium to maintain coverage, and expenses outside the plan’s applicable limit could still remain.
Does the Deductible Count Toward the Out-of-Pocket Maximum?
Qualifying deductible payments generally count toward the Marketplace out-of-pocket maximum.
That means you do not normally pay the full deductible and then start counting toward the out-of-pocket maximum from zero.
Instead, qualifying deductible spending is part of the total that moves you toward the annual limit.
Example: if your deductible is $2,500 and your out-of-pocket maximum is $8,000, qualifying payments toward that $2,500 deductible are generally part of the $8,000 total rather than an additional expense on top of it.
Do Copays and Coinsurance Count?
For Marketplace plans, qualifying copayments and coinsurance for covered in-network care generally count toward the out-of-pocket maximum.
This can include applicable cost sharing for physician visits, hospital services, laboratory work, prescriptions, or other covered benefits, depending on the plan.
Because benefit designs can be complicated, check the plan documents if it is unclear whether a particular charge is credited toward your limit.
Does Your Monthly Premium Count?
No. Your monthly health insurance premium does not count toward the Marketplace out-of-pocket maximum.
This is why the out-of-pocket maximum should not be interpreted as the absolute maximum amount health coverage can cost you during the year.
A useful high-cost-year comparison is:
Annual Premium + Out-of-Pocket Maximum
This calculation can help compare financial exposure for covered in-network services, but it is not a guarantee of your absolute maximum spending because excluded services and other non-qualifying charges may remain outside the limit.
Cost-Sharing Reductions Can Lower the Maximum
Some Marketplace shoppers qualify for additional savings known as cost-sharing reductions.
Cost-sharing reductions can lower deductibles, copayments, coinsurance, and the out-of-pocket maximum for eligible consumers.
For income-based Marketplace cost-sharing reductions, consumers generally must select an eligible Silver plan to receive the extra savings.
Premium assistance and cost-sharing assistance are different. A premium tax credit can lower the monthly insurance premium, while cost-sharing reductions can lower eligible out-of-pocket costs when medical care is used.
Why the Out-of-Pocket Maximum Matters When Comparing Plans
Consumers sometimes compare a plan’s premium and deductible but ignore its out-of-pocket maximum.
That can hide an important difference between two health plans.
| Hypothetical Feature | Plan A | Plan B |
|---|---|---|
| Monthly premium | $300 | $410 |
| Deductible | $5,500 | $2,000 |
| Out-of-pocket maximum | $9,500 | $6,000 |
| Potential trade-off | Lower premium but greater financial exposure if substantial care is needed. | Higher premium but a lower ceiling on qualifying cost sharing. |
Someone expecting very little medical care might prefer Plan A’s lower premium. Someone concerned about significant health care spending might place greater value on Plan B’s lower deductible and out-of-pocket maximum.
The example is hypothetical and illustrates why no single plan feature should determine your choice.
Individual vs. Family Out-of-Pocket Maximums
Family health plans can have more complicated cost-sharing structures than individual plans.
The plan documents may show individual and family deductibles, individual and family out-of-pocket limits, or specific rules describing how spending by each family member contributes toward the applicable limits.
Do not assume every family plan accumulates expenses in exactly the same way. Review the Summary of Benefits and Coverage and ask the insurer how the limits work when more than one family member receives medical care.
Not Every Type of Health Coverage Uses the Same Limit
The 2026 limits discussed above apply to Marketplace health plans and should not be assumed to describe every type of health coverage.
Employer-sponsored plans may have their own applicable limits and cost-sharing structures under federal and plan rules.
Medicare also works differently. Original Medicare does not have one overall yearly limit on what a beneficiary pays out of pocket unless the person has supplemental coverage that provides additional protection. Medicare Advantage plans, by contrast, have annual limits for covered Medicare services, with the exact amount varying by plan.
Always compare the rules for the type of coverage you actually have. A Marketplace plan, employer plan, Original Medicare, and Medicare Advantage plan should not automatically be assumed to use identical cost-sharing limits.
How to Compare Out-of-Pocket Maximums
When comparing health insurance plans, use the out-of-pocket maximum together with the other major cost variables.
- What is the monthly premium?
- What is the deductible?
- What copayments apply to services you use frequently?
- What coinsurance percentages apply after the deductible?
- What is the individual out-of-pocket maximum?
- What is the family out-of-pocket maximum, if applicable?
- Which expenses count toward the limit?
- Are your doctors and hospitals in network?
- How are prescription costs treated?
- Do you qualify for cost-sharing reductions or other financial assistance?
Frequently Asked Questions
The Bottom Line
An out-of-pocket maximum limits how much qualifying cost sharing you must pay during a plan year for applicable covered health care. Deductibles, copayments, and coinsurance for covered in-network services generally contribute toward a Marketplace plan’s limit.
For 2026 Marketplace coverage, the federal ceiling is $10,600 for an individual and $21,200 for a family, although individual plans can use lower limits. Monthly premiums, non-covered services, and many out-of-network expenses remain outside the maximum.
When comparing health plans, look at the out-of-pocket maximum alongside the premium, deductible, copayments, coinsurance, provider network, and prescription benefits. That provides a much clearer picture of both your expected spending and your potential financial exposure in a high-cost medical year.
Sources
- HealthCare.gov, Out-of-Pocket Maximum/Limit, accessed August 2026.
- HealthCare.gov, Your Total Costs for Health Care: Premium, Deductible, and Out-of-Pocket Costs, accessed August 2026.
- HealthCare.gov, Cost-Sharing Reductions, accessed August 2026.
- Centers for Medicare & Medicaid Services, Health Insurance Terms You Should Know, updated August 2026.
- Medicare.gov, Compare Original Medicare & Medicare Advantage, accessed August 2026.