Out-of-Pocket Maximums: What Counts and What Doesn't

What the out-of-pocket maximum covers, the 2026 and 2027 federal ceilings, what never counts toward it, and how the limit works on family plans.

iHealthBenefit · Last reviewed October 26, 2026 · 6 min read

The out-of-pocket maximum is the single most protective number in a health plan. It is the point at which your share of covered, in-network costs stops for the rest of the plan year, no matter how much more care you need.

It is also easy to misread. Premiums never count toward it, out-of-network bills often don't, and family plans apply it in a way many people don't expect. This guide explains what the limit is, what the federal ceiling is for 2026 and 2027, what counts toward it and what doesn't.

This is general information, not insurance, tax, legal or medical advice. Your plan's Summary of Benefits and Coverage and policy documents control how your own limit works.

What the out-of-pocket maximum is

HealthCare.gov defines the out-of-pocket maximum (also called the out-of-pocket limit) as the most you have to pay for covered services in a plan year. After you spend that amount on deductibles, copayments and coinsurance for in-network care and services, your plan pays 100% of the costs of covered benefits.

HealthCare.gov's worked example shows the effect. Once the person in the example has paid her plan's full out-of-pocket maximum by October, the plan pays all costs for covered health services through the end of the coverage period, which it notes is usually December 31. The next plan year starts the count again from zero.

The federal ceiling for 2026 and 2027

The Affordable Care Act caps how high a plan's out-of-pocket maximum can be. For 2026 Marketplace plans, HealthCare.gov lists a limit of no more than $10,600 for an individual or $21,200 for a family. For 2027 plans, it lists no more than $12,000 for an individual or $24,000 for a family.

A few points about that ceiling:

It is a maximum, not a typical value. A plan may set a lower limit, as the Departments of Labor, Health and Human Services and the Treasury noted in their joint ACA FAQs Part XXVII (May 26, 2015).
It is not only for Marketplace plans. The same FAQs state that the limit applies to all non-grandfathered group health plans, including self-insured and large group plans.
Under the federal rule at 45 CFR 156.130, the limit for coverage other than self-only is twice the self-only limit.
The cap protects out-of-pocket costs for essential health benefits, according to the FAQs. Grandfathered plans are not subject to it.

High-deductible health plans that pair with health savings accounts have their own, separate IRS limits, which are covered in our guide to high-deductible health plans.

What counts toward the limit

For in-network, covered care, three kinds of payments count:

Deductibles, including separate deductibles such as a prescription drug deductible
Copayments
Coinsurance

Each time you pay one of these for a covered in-network service, your running total goes up. Keeping your explanation of benefits statements makes it easier to check that total yourself.

What doesn't count

HealthCare.gov lists four things the out-of-pocket limit doesn't include:

Your monthly premiums.
Anything you spend for services your plan doesn't cover.
Out-of-network care and services.
Costs above the allowed amount for a service that a provider may charge.

The out-of-network rule comes from the federal regulation itself. Under 45 CFR 156.130(c), a plan that uses a provider network is not required to count cost sharing for out-of-network benefits toward the annual limit. Plans that do cover out-of-network care may set a separate out-of-network limit; the Department of Labor's sample Summary of Benefits and Coverage, for example, shows one that is higher than the in-network limit.

Drug manufacturer coupons are another gray area. The same regulation says amounts paid by drug manufacturer assistance may be, but are not required to be, counted toward the limit, to the extent consistent with state law. If you use a copay card, ask your plan how it is treated.

Exceptions: when out-of-network costs count anyway

Federal surprise-billing rules carve out important exceptions. Under the No Surprises Act regulations at 45 CFR 149.110, cost sharing you pay for covered emergency services from an out-of-network provider must be counted toward your in-network deductible and in-network out-of-pocket maximum, as if the care were in-network.

CMS's overview of No Surprises Act protections (revised June 2026) describes a similar rule when a plan's provider directory was wrong. If you went out-of-network because the directory listed the provider as in-network, your cost sharing can't exceed the in-network amount, and the plan must count it toward your in-network deductible and out-of-pocket maximum.

How the limit works on a family plan

Family plans usually have both an individual and a family out-of-pocket maximum. Federal guidance adds a protection many people don't know about: the self-only limit applies to each individual, even when that person is enrolled in family coverage. The joint ACA FAQs Part XXVII explain that this has applied to non-grandfathered plans since plan years beginning in 2016, including high-deductible health plans.

In practice, consider a hypothetical family plan in 2026 with an $18,000 family out-of-pocket maximum. Even though the family limit is $18,000, no single family member can be required to pay more than the 2026 self-only limit HealthCare.gov lists, $10,600, toward their own covered in-network care. If one person has a very expensive year, the plan must start paying that person's covered costs in full once they hit the individual limit, while other family members keep paying cost sharing until the family total reaches $18,000.

The Department of Labor's sample Summary of Benefits and Coverage phrases it simply: family members have to meet their own out-of-pocket limits until the overall family limit has been met.

Using the limit to plan your budget

The out-of-pocket maximum is the most useful number for a worst-case estimate. Add twelve months of premiums to the plan's in-network out-of-pocket maximum, and you have roughly the most you would spend in a year on covered, in-network care. Then consider what that figure leaves out: services the plan excludes, out-of-network care that isn't protected, and balance bills.

When you compare plans, look at two rows on page one of each plan's Summary of Benefits and Coverage: "What is the out-of-pocket limit for this plan?" and "What is not included in the out-of-pocket limit?" The answers are written in a standard format, which makes side-by-side comparison easier.

Where to get personal help

If you think your plan has miscounted your costs, call the member services number on your insurance card and ask for a breakdown of what has been applied to your out-of-pocket maximum. For job-based plans covered by federal benefits law, the Department of Labor's Employee Benefits Security Administration offers help at 1-866-444-3272. For individual and Marketplace plans, your state insurance department can take complaints; the NAIC keeps a directory of every state's department.

Key takeaways

The out-of-pocket maximum is the most you pay for covered, in-network care in a plan year; after that, the plan pays 100%.
For 2026, HealthCare.gov lists a ceiling of $10,600 individual and $21,200 family; for 2027, $12,000 and $24,000. A plan may set a lower limit.
Premiums, uncovered services, most out-of-network care and balance bills don't count toward it.
Out-of-network emergency cost sharing must count toward your in-network limit under federal surprise-billing rules.
On a family plan, no one person pays more than the self-only limit.

Sources

Our articles are general information, not medical, insurance, tax or legal advice, and we don't sell insurance or recommend specific plans or companies.

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