Out-of-pocket maximum
Updated September 30, 2026
Definition
The most you pay in a plan year for covered, in-network care. After you reach it, your plan pays 100% of covered costs for the rest of the year.
Your out-of-pocket maximum is a cap on what you pay for covered care in a plan year. Your deductible, copays, and coinsurance for in-network care all count toward it. Once you reach it, your plan pays 100% of covered costs until the plan year ends.
Some costs don't count. Your monthly premium doesn't. Neither does care your plan doesn't cover, most out-of-network care, or any amount above your plan's allowed amount. For 2026, Marketplace plans can't set this limit higher than $10,600 for 1 person or $21,200 for a family.
For example, say your limit is $5,000 and you've paid $4,600 so far this year. Your share of a new claim comes to $1,200. You owe only $400, and your plan pays the other $800. If a bill asks for more after you've reached your limit, ask the provider and your plan to check it.
Related terms
Guides that use this term
- GuideHow to choose a health insurance plan and avoid big billsCompare health plans by total yearly cost, not just the premium. Check networks, doctors, drugs and the SBC, with a worked example and 2027 deadlines.
- GuideMedical bill vs. EOB: how to compare them line by lineYour bill and your EOB should tell the same story. Here's how to compare them in 20 minutes, with a worked example and what to do if they don't match.
Sources
- Out-of-pocket maximum/limit (glossary), HealthCare.gov. Accessed September 30, 2026.
- Health insurance terms you should know, Centers for Medicare & Medicaid Services. Accessed September 30, 2026.
This is general information, not legal or medical advice. Rules can depend on your plan and your state. Romi Care isn't an insurer, law firm, collection agency, or government program.