Your out-of-pocket maximum is the most you'll pay for covered in-network care in a single plan year. Once you hit that number, your plan pays 100% of covered essential health benefits for the rest of the year.
Three costs count toward it:
Your monthly premium does not count. Neither do out-of-network charges on most plans, or anything your plan doesn't cover at all.
Federal maximums by plan year:
The jump from 2026 to 2027 is about 13.2%, one of the larger single-year increases since the ACA took effect. If you're comparing plans for 2027, the worst-case exposure is meaningfully higher than what you may be used to.
These are ceilings, not typical values. Plans routinely set limits well below the federal cap, and if you qualify for Cost-Sharing Reductions on a Silver plan, your actual maximum can be dramatically lower.
HSA-qualified high-deductible plans follow separate, lower IRS limits: $8,700 individual / $17,400 family for 2027. Marketplace Bronze and Catastrophic plans are classified as high-deductible but still follow the regular ACA ceiling above, not the HSA one.
Want to know your actual exposure on a specific plan? Call us at (305) 330-1277.
No. Your deductible is what you pay before your plan starts sharing costs. Your out-of-pocket maximum is the total ceiling for the year, and your deductible counts toward reaching it.
Family plans include both a family limit and an embedded individual limit. Once any one family member reaches the individual maximum, their covered care is paid at 100% for the rest of the year, even if the family total hasn't been met.
Yes, and the increase is significant. The 2027 federal ceiling is $12,000 individual and $24,000 family, up from $10,600 and $21,200 in 2026. Check the specific out-of-pocket maximum on any plan you're considering rather than assuming it matches last year's.
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