Out-of-pocket maximum

What It Means

The out-of-pocket maximum, also called the out-of-pocket limit, is the most you have to pay for covered services in one plan year. Your deductible, copaysCopayA fixed dollar amount, such as $20, that you pay for a covered health care service under your health insurance plan. See more and coinsuranceCoinsuranceYour share of the cost of a covered health care service, set as a percentage such as 20%, that you pay after meeting your deductible. See more for covered in-networkIn-networkDescribes a doctor, hospital or other provider that has a contract with your health plan, so you usually pay less for covered care than you would outside the network. See more care all count toward it, and once they add up to the maximum, the plan pays 100% of covered benefitsBenefits packageEverything an employer offers on top of wages, such as health insurance, paid leave and a retirement plan, which can be worth thousands of dollars a year. See more for the rest of that year. PremiumsInsurance premiumThe amount you pay to keep an insurance plan, such as health insurance, in force, usually monthly, quarterly or yearly, whether or not you use any care. See more, care the plan doesn't cover and out-of-networkOut-of-networkDescribes a provider that has no contract with your health plan, so the plan pays less or nothing for the care and you may be billed more. See more care don't count toward it.

How People Say It

• "We hit our out-of-pocket max in March, so the rest of the year is covered."
• "What's the max on that plan, family or individual?"
• "Premiums don't count toward it? Seriously?"

The Breakdown

Formula

Left to pay before the plan covers everything = out-of-pocket maximum minus (deductible paid + copays paid + coinsurance paid), counting only covered in-network care.

Worked example. One adult on a plan with a $6,000 out-of-pocket maximum, partway through the year. The numbers are an example:

$6,000 minus $3,500 leaves $2,500. Once this person pays another $2,500 in deductible, copays or coinsurance for covered in-network care, the plan pays 100% of covered benefits until the plan year ends.

What the result means. The maximum is a ceiling on your share of covered care, so it tells you the worst case for a year of covered in-network bills. Your total cost for the year is that figure plus premiums, plus anything the maximum leaves out.

2026 Marketplace limits. HealthCare.gov says the out-of-pocket limit for a 2026 Marketplace plan can be no more than $1010,000 stepsA popular daily step goal that began as the name of a 1960s Japanese pedometer; later studies find health benefits begin well below it. See more,600 for an individual and $21,200 for a family. Many plans set a lower one, so read your own plan's figure.

Good to Know

HealthCare.gov's glossary lists four things that never count toward the out-of-pocket limit: your monthly premiums, spending on services the plan doesn't cover, out-of-network care and services, and any amount a provider charges above the plan's allowed amount. Those can keep costing you after you reach the maximum, so keep each bill and its explanation of benefitsExplanation of benefitsA statement from your health plan, not a bill, that shows what a provider charged for a visit, what the plan paid and what you may owe. See more and check which bucket it falls in. The limits above are for 2026 Marketplace plans; a job-based plan states its own maximum in its plan documents.

Related Terms and Categories

• Health insurance deductible

  What you pay on your own for covered health care before your health insurance plan begins sharing the cost.

• Copay

  A fixed dollar amount, such as $20, that you pay for a covered health care service under your health insurance plan.

• Coinsurance

  Your share of the cost of a covered health care service, set as a percentage such as 20%, that you pay after meeting your deductible.

• Insurance premium

  The amount you pay to keep an insurance plan, such as health insurance, in force, usually monthly, quarterly or yearly, whether or not you use any care.

• In-network

  Describes a doctor, hospital or other provider that has a contract with your health plan, so you usually pay less for covered care than you would outside the network.

• Out-of-network

  Describes a provider that has no contract with your health plan, so the plan pays less or nothing for the care and you may be billed more.

Planning and life admin