Quick answer
The out-of-pocket maximum is the most you’ll pay for covered, in-network care in a plan year. Your deductible, copays and coinsurance all count toward it. Once you reach it, your plan pays 100% of covered in-network care for the rest of the year. For 2026, ACA plans can’t set it above $10,600 for one person or $21,200 for a family, and the caps rise to $12,000 and $24,000 in 2027.
Key takeaways
- Deductibles, copays and coinsurance for covered in-network care count toward the limit. Premiums don’t.
- Out-of-network care, services your plan doesn’t cover and balance bills usually don’t count.
- On a family plan, no one person pays more than the individual limit.
- Many plans set their limit below the federal cap, and low-income silver plan enrollees get much lower limits through cost-sharing reductions.
- The limit resets at the start of every plan year.
On this page
How the out-of-pocket maximum works
Say your plan has a $2,000 deductible, 20% coinsurance and a $7,000 out-of-pocket maximum, and you have a $60,000 surgery and hospital stay:
| Step | You pay | Your plan pays |
|---|---|---|
| First $2,000 of the bill | $2,000 (deductible) | $0 |
| Next $25,000 | $5,000 (20% coinsurance), reaching the $7,000 limit | $20,000 |
| Remaining $33,000 | $0 | $33,000 |
| Total | $7,000 | $53,000 |
Without the limit, 20% of that bill after the deductible would have cost you $11,600.
What counts and what doesn’t
Counts toward the limit:
- Your deductible
- Coinsurance
- Copays, including prescription copays for covered drugs
Doesn’t count:
- Monthly premiums
- Services your plan doesn’t cover
- Most out-of-network care, unless your plan has a separate out-of-network limit or it’s an emergency
- Balance bills, where a provider charges more than your plan allows
2026 and 2027 limits
| Plan type | 2026 | 2027 |
|---|---|---|
| ACA plan, one person | $10,600 | $12,000 |
| ACA plan, family | $21,200 | $24,000 |
| Traditional HSA-qualified plan, one person | $8,500 | $8,700 |
| Traditional HSA-qualified plan, family | $17,000 | $17,400 |
The ACA limits apply to marketplace plans and to nearly all job-based plans. Original Medicare has no out-of-pocket limit, but Medicare Advantage plans must have one, and Part D caps drug costs at $2,100 in 2026 ($2,400 in 2027).
Family plans
Family plans have two limits. Each person has an individual limit, and the family has a combined one. Under ACA rules, no one on a family plan pays more than the individual cap, $10,600 in 2026, even if the family limit is higher. Once the family’s combined spending reaches the family limit, the plan pays 100% of covered in-network care for everyone.
Why it matters when you choose a plan
The out-of-pocket maximum shows your worst-case year. Add up 12 months of premiums plus the limit to see the most you could spend on covered in-network care. A plan with a lower premium and a $10,000 limit can cost more in a bad year than a pricier plan with a $4,000 limit.
If your income is under 250% of the federal poverty level, look at silver plans on the marketplace. Cost-sharing reductions lower their deductibles and out-of-pocket limits, sometimes to a small fraction of the federal cap.
Compare out-of-pocket limits for plans near you: see plans by ZIP code.
Frequently asked questions
Does the out-of-pocket maximum include premiums?
No. You keep paying premiums after you reach the limit.
Does out-of-network care count?
Usually not, unless it’s emergency care or your plan has a separate out-of-network limit. Out-of-network costs can keep adding up with no cap.
What happens if I change plans mid-year?
Most of the time you start at $0 with the new plan’s deductible and limit. Ask the new insurer whether it credits what you’ve already paid.
Do prescription drugs count toward the limit?
Yes, covered drugs count. Drugs your plan doesn’t cover don’t.
Sources
This article is general information, not insurance advice. Limits and covered services vary by plan, so check your plan’s summary of benefits or ask your insurer. Last reviewed September 2026.