The amount you pay out of your own pocket for covered health care services before your insurance plan starts sharing costs.
For example, if you have a $1,500 deductible, you pay the first $1,500 of covered care yourself. Once you meet your deductible, your plan begins paying its share. That's where copays come in. A copay is a fixed amount you pay for a covered service (like $30 for a doctor visit), even after your deductible is met.
No matter how much care you need in a year, your spending has a ceiling. That's your out-of-pocket maximum, the most you'll ever pay in a plan year. Once you hit that limit, your insurance covers 100% of covered costs for the rest of the year.
How your deductible works with your copay and out-of-pocket maximum:
A step-by-step walkthrough showing how the deductible, copay, and out-of-pocket maximum interact during a plan year on an ACA Marketplace Silver plan.
Stage
What Happens
Who Pays
Your Running Total
Before Deductible
You get care before hitting your deductible (e.g., an urgent care visit billed at $400).
You pay the full $400.
$400 toward your $1,500 deductible
Deductible Met
Another $1,100 in covered services. You've now hit your $1,500 deductible.
You pay $1,100. Deductible is now met.
$1,500 — deductible met ✓
Copay Kicks In
You see your primary care doctor. The visit is billed at $200, but your copay is $30.
You pay $30. Plan pays the remaining $170.
$1,530 toward your $4,500 out-of-pocket max
Out-of-Pocket Max Reached
A hospital stay. Your share after insurance is $2,970 in coinsurance.
You pay $2,970. Out-of-pocket max is now hit.
$4,500 — out-of-pocket max reached ✓
Fully Protected
Any additional covered care for the rest of the plan year.
Your plan pays 100%. You pay $0.
$4,500 — you're fully protected for the year
Example uses a hypothetical ACA Silver plan with a $1,500 deductible, $30 primary care copay, and $4,500 out-of-pocket maximum. Actual costs vary by plan. For 2026, the federal out-of-pocket maximum is $10,600 for individuals and $21,200 for families.
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