Your out-of-pocket maximum is the most you’ll ever pay for covered health care in a single benefit year. Once you hit that number, your insurance pays 100% of covered costs for the rest of the year — no more deductibles, copays, or coinsurance.
Three costs count toward your out-of-pocket maximum:
Your monthly premium does NOT count toward it. Neither do out-of-network charges (on most plans) or costs for non-covered services.
For 2026, the federal out-of-pocket maximum limits are:
Plans can set lower limits than the federal cap — and if you qualify for Cost-Sharing Reductions (CSR), your actual out-of-pocket maximum could be significantly lower than the federal ceiling.
No. Your deductible is the amount you pay before insurance starts sharing costs. Your out-of-pocket maximum is the total ceiling for the year across all cost-sharing. Once you’ve paid enough in deductible, copays, and coinsurance to hit the out-of-pocket max, you stop paying entirely for covered care that year.
Family plans have both an individual embedded limit and a family limit. Once any single family member hits their individual out-of-pocket maximum, the plan covers 100% of that person’s covered costs for the rest of the year — even if the family limit hasn’t been reached yet. Once the family limit is hit, everyone is covered at 100%.
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