An out-of-pocket maximum is the most you pay in a plan year for covered care that counts under your health plan’s rules. Once you reach it, the plan generally pays 100% of covered benefits for the rest of that plan year. It is not a cap on every health expense: premiums, some out-of-network care, non-covered services, and charges above the plan’s allowed amount may remain your responsibility.
How an out-of-pocket maximum works
Think of the out-of-pocket maximum as a ceiling on qualifying cost sharing—not as the point at which all health care becomes free. You may pay a deductible first, then continue to owe copayments or coinsurance. Eligible amounts accumulate toward the plan’s limit. After you reach it, the plan pays 100% of covered benefits that count for the remainder of the plan year, subject to the policy’s terms. HealthCare.gov’s Marketplace glossary defines the limit and the coverage that follows it.
A deductible and an out-of-pocket maximum are related but different. The deductible is what you pay for covered services before the plan usually begins paying its share. The maximum includes qualifying cost sharing such as the deductible, copayments, and coinsurance, up to the plan’s limit.
Illustrative coinsurance example
HealthCare.gov illustrates the math with a $3,000 deductible, 20% coinsurance, $12,000 in allowed costs, and a $6,850 out-of-pocket maximum. In that example, the member pays $3,000 toward the deductible and 20% of the remaining $9,000, or $1,800, for a total of $4,800. These are example amounts, not a standard plan design or the 2026 federal limit. HealthCare.gov’s coinsurance glossary explains the example.
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What counts toward the limit—and what does not
For Marketplace coverage, covered in-network deductibles, copayments, and coinsurance count toward the out-of-pocket limit. But not every payment related to health care counts, and the exact rules depend on the plan. HealthCare.gov cautions that some plans do not count every payment or expense toward the limit; the plan policy and Summary of Benefits and Coverage (SBC) control. HealthCare.gov’s glossary of health coverage terms describes this qualification.
- Usually excluded from the Marketplace limit: monthly premiums; care the plan does not cover; out-of-network care; and charges above the allowed amount, such as a provider’s charge in excess of the amount recognized by the plan. See HealthCare.gov’s out-of-pocket maximum glossary.
- Plan-specific: whether a particular payment counts. Check the SBC and policy for the plan’s limit, network rules, and counting rules before estimating your exposure.
HealthCare.gov defines cost sharing as amounts paid for covered care, such as deductibles, coinsurance, and copayments, and distinguishes those amounts from premiums and non-covered care. See its cost-sharing glossary.
2026 Marketplace out-of-pocket limits
For Marketplace plans in plan year 2026, the out-of-pocket limit cannot exceed $10,600 for an individual or $21,200 for a family. These are federal ceilings, not the guaranteed limit for a specific plan; a plan may set a lower amount. The applicable plan document shows the actual limit and how it works. HealthCare.gov lists the plan-year limits.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.How to compare plans using the maximum
A lower maximum can reduce your potential cost sharing for covered care, but it does not by itself tell you which plan will cost less. Compare the costs and coverage together:
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- Deductible: what you pay for covered services before the plan usually starts sharing costs.
- Copayments and coinsurance: what you may owe for covered care under the plan’s rules.
- Out-of-pocket maximum: the ceiling on qualifying cost sharing, not on premiums or every possible medical bill.
- Network and covered services: out-of-network and non-covered care may be outside the limit, so confirm whether your providers and expected services are covered.
Estimate your annual premium plus likely cost sharing rather than comparing premiums alone. HealthCare.gov recommends considering total annual costs when selecting a plan. Its plan-selection guidance explains premiums, deductibles, and out-of-pocket costs.
Check whether cost-sharing reductions apply
Some Marketplace consumers qualify for cost-sharing reductions, which can lower deductibles, copayments, coinsurance, and the out-of-pocket maximum. To receive these savings, an eligible consumer must enroll in a Silver plan; not every Silver enrollee qualifies. Eligibility is determined through the Marketplace application. HealthCare.gov explains cost-sharing reductions.
Quick Recap
Find the rule for your own plan
- Open the plan’s Summary of Benefits and Coverage and find the out-of-pocket limit for individual or family coverage.
- Review the policy for what counts toward the limit and whether separate rules apply to in-network and out-of-network care.
- Check whether your expected services and providers are covered and in network.
- Compare the premium, deductible, copayments, coinsurance, and maximum together to estimate your potential annual spending.
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