What Is Out-of-Pocket Maximum?
The out-of-pocket maximum is the most you pay for in-network covered care in a plan year — combining your deductible, copays, and coinsurance. Once you reach it, the plan pays 100% of covered services for the rest of the year. The ACA sets inflation-adjusted caps (about $9,200 individual / $18,400 family for 2026).
Why it matters
It is your financial ceiling against a catastrophic year, which is why it matters more than the premium when judging a plan.
Common confusion
Premiums do NOT count toward the out-of-pocket max; only cost-sharing (deductible/copay/coinsurance) does.
Frequently Asked Questions
Do out-of-network costs count?
Generally no, unless it is an emergency or your plan has out-of-network coverage that includes it — read the specifics.
What happens after I hit it?
The insurer pays 100% of covered in-network care for the rest of the plan year.