Out-of-Pocket Maximum Explained: What It Covers and What It Does Not

The out-of-pocket maximum is one of the most important numbers on your health plan. It is also one of the most misunderstood. Many people assume it caps all their healthcare costs for the year. It does not. Here is what it actually does.

What counts toward your out-of-pocket maximum

Your out-of-pocket maximum accumulates from three types of cost-sharing payments: your deductible, copays, and coinsurance for covered in-network services. Once the total of these payments reaches your maximum, your insurer pays 100 percent of covered in-network services for the rest of the plan year.

ACA-compliant plans have a federal limit on how high out-of-pocket maximums can be set. In 2026, the limit is $9,450 for individual coverage and $18,900 for family coverage. Many plans set lower limits as a competitive benefit.

What does not count toward your out-of-pocket maximum

Premiums. Your monthly premium payments never count toward your out-of-pocket maximum regardless of how much you pay.

Out-of-network costs. Most plans have a separate, higher out-of-pocket maximum for out-of-network care, or no maximum at all for out-of-network providers. Balance bills from out-of-network providers generally do not count.

Services your plan does not cover. If your plan excludes a service, any amount you pay for it does not count toward your maximum.

Amounts above the allowed rate. If a provider charges $600 and your insurer's allowed amount is $400, you may be responsible for the $200 difference in some circumstances. That difference may not count toward your maximum.

Copays for certain services on some plans. This depends on your specific plan. Read your Summary of Benefits carefully.

Family out-of-pocket maximum rules

Family plans have both individual and family out-of-pocket maximums. Under ACA rules, once any individual family member meets the individual maximum, the plan pays 100 percent for that person even if the family maximum has not been reached. No single family member can be required to pay more than the individual maximum.

This matters most for families with one high-cost member. If one person has major surgery, they hit the individual maximum and the plan covers them fully while other family members continue accumulating costs until they individually hit their limits or the family maximum is reached.

How to track your progress

Your insurer's member portal or app typically shows your year-to-date deductible and out-of-pocket accumulation. Check it before scheduling expensive care so you know exactly where you stand.

If you are close to your maximum in the fall, it may make sense to schedule elective care before January 1 when everything resets. If you are far from your maximum in December with no expected care needs, postponing discretionary services to January preserves your reset deductible.

What happens when you hit your maximum

Once you reach your out-of-pocket maximum, submit all bills to your insurer even for services you previously paid out of pocket during the year. The insurer should process them at zero cost-sharing for you. If a provider sends you a bill after you have hit your maximum, call your insurer before paying.

Keep records of all payments throughout the year. Errors in accumulation tracking happen. If your insurer's records show a different total than yours, request an itemized payment history and compare it against your own receipts.

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Bill Advantage is a document literacy tool. Nothing in this article constitutes legal or medical advice.