Cost sharing
Out-of-pocket maximum: the cap, and what it excludes
Checked 7 November 2026 against the sources at the bottom. Health insurance rules change. Confirm the official page before you enroll.
HealthCare.gov defines the out-of-pocket maximum 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, the plan pays 100% of the costs of covered benefits.
What the limit does not include
- Your monthly premium.
- Care the plan does not cover.
- Out-of-network care and services.
- Amounts above the allowed amount that a provider may bill.
Hitting the maximum does not pay you back for premiums, and it does not cap a bill for something the plan never covered. That is why a low out-of-pocket maximum on an out-of-network-heavy year can still leave a large bill.
Marketplace caps are not your plan’s number
HealthCare.gov publishes a ceiling for Marketplace plans. For 2026 it lists no more than $10,600 for an individual or $21,200 for a family. For 2027 it lists no more than $12,000 for an individual or $24,000 for a family. A specific plan can set a lower limit. Plans sold outside the Marketplace do not have to use these Marketplace ceilings. Ask which product you are looking at before you compare the figures.
Put this number next to the deductible and the coinsurance when you compare plans. The maximum is the worst case for covered in-network care, not the typical month.