Insurance Basics
What Is an Out-of-Pocket Maximum?
By the PolicyZen Team · Updated March 2026 · 7 min read
Your out-of-pocket maximum (also called out-of-pocket limit) is the most money you will ever have to pay for covered healthcare in a single plan year. Once you hit that number, your insurance covers 100% of all remaining in-network covered costs for the rest of the year — no deductible, no copays, no coinsurance.
It is, in simple terms, your annual catastrophic loss cap.
Example: Your plan has a $7,000 out-of-pocket maximum. You're diagnosed with cancer in March. Between your deductible, copays, and coinsurance, you pay $7,000 by June. Every covered in-network claim from July through December is paid at 100% by your insurer. Your total exposure for the year is capped at $7,000 — regardless of how many hundreds of thousands of dollars in care you receive.
What Counts Toward Your Out-of-Pocket Maximum
These payments accumulate toward your out-of-pocket max:
- Your annual deductible
- Copays for covered in-network services
- Coinsurance for covered in-network services
What Does NOT Count Toward Your Out-of-Pocket Maximum
This is where many people get blindsided:
- Your monthly premium — the money you pay just to have insurance does not count
- Out-of-network costs — if you go out-of-network on a plan with separate OON limits, those costs track separately (or not at all)
- Non-covered services — if your plan doesn't cover something, your payments for it don't count
- Costs above the allowed amount — if an out-of-network provider charges more than your plan's allowed amount, the excess is yours and doesn't count
- Prescription drug costs (on some plans) — some plans have separate drug cost-sharing that tracks independently
The premium trap: A common misconception — people believe once they've paid enough in premiums, insurance should cover everything. Premiums are the price of having the policy. They are completely separate from your out-of-pocket maximum. Even if you've paid $10,000 in premiums this year, you could still owe your full out-of-pocket maximum on top of that.
ACA Out-of-Pocket Limits for 2026
The Affordable Care Act sets maximum limits on out-of-pocket costs for ACA-compliant plans. For 2026:
| Coverage Type | 2026 Maximum |
|---|
| Individual | $9,200 |
| Family | $18,400 |
No ACA-compliant plan can have an out-of-pocket maximum higher than these limits. Grandfathered plans and some employer-sponsored plans may have different rules.
Individual vs. Family Out-of-Pocket Maximum
Family plans have two out-of-pocket limits: one per individual and one for the whole family. Once any family member hits their individual limit, the plan covers them at 100% for the rest of the year — even if the family total hasn't been reached. Once the family aggregate is reached, everyone is covered.
Embedded vs. Aggregate Family OOP Max
Embedded: Each family member has their own individual limit. When they hit it, they're covered. The family also has a combined limit. This is more protective for families where one member needs significant care.
Aggregate only: The whole family must collectively reach one combined limit before anyone is at 100% coverage. This can be brutal — one sick family member spends $9,000 but the family OOP max is $18,400, so they still owe more even though one person's care was catastrophic.
Frequently Asked Questions
Does my out-of-pocket maximum reset every year?
Yes. It resets on your plan anniversary date (usually January 1). There is no carryover. If you hit your OOP max in November, you start from zero again in January.
Can my out-of-pocket maximum be lower than my deductible?
No. By definition, your out-of-pocket maximum must be equal to or higher than your deductible. Your deductible is one component that contributes to reaching the OOP max. A plan with a $3,000 deductible must have an OOP max of at least $3,000.
After I hit my out-of-pocket max, do I still pay copays?
For most ACA-compliant plans, no. Once you hit your out-of-pocket maximum, all covered in-network services are paid at 100% — no copays, no coinsurance. However, always verify with your specific plan, as some older grandfathered plans may not follow this rule.
How do I track how much I've paid toward my out-of-pocket max?
Log into your insurer's member portal — most track your year-to-date deductible and out-of-pocket accumulation in real time. Your Explanation of Benefits (EOB) documents also show running totals. You can also call member services and ask directly: "How much have I accumulated toward my out-of-pocket maximum this year?"
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