Out-of-Pocket Maximum
The out-of-pocket maximum is the most you will pay for covered, in-network care in a plan year, after which the plan pays 100%.
The ceiling on your yearly costs
The out-of-pocket maximum, sometimes called the OOP max, is your financial safety net. Every deductible dollar, coinsurance payment and copay for covered in-network care adds up toward it. Once you reach the cap, the plan pays the full cost of covered in-network services for the rest of the plan year.
What does not count: your monthly premiums, care your plan does not cover, and, on most plans, out-of-network charges.
2027 federal limits
For ACA-compliant plans, the federal government sets the highest OOP max a plan can carry:
- 2027: $12,000 for self-only coverage and $24,000 for family coverage.
- 2026: $10,600 self-only and $21,200 family.
These are ceilings. Many plans set their cap lower, and gold plans often sit well below the limit. The jump from 2026 to 2027 is meaningful, so if you are renewing, check whether your plan's cap moved.
Worked example
Maria is a real estate agent with a silver plan: $5,000 deductible, 30% coinsurance, and a $9,500 out-of-pocket maximum. In June she has an emergency surgery with a negotiated bill of $60,000.
- She pays the $5,000 deductible.
- She owes 30% of the rest until her total hits $9,500. That takes another $4,500.
- After that, the plan covers 100% of in-network care through December 31.
Without the cap, 30% of the remaining $55,000 would have been $16,500. The OOP max is what keeps a serious year from becoming a financial crisis.
Embedded caps on family plans
Family plans include an individual cap inside the family cap. One family member cannot be asked to pay more than the self-only limit, even if the family total has not been reached. That protects households where one person has a big medical year.
Marketplace vs private plans
All ACA-compliant plans, on or off the Marketplace, must follow the federal cap. Silver plans with cost-sharing reductions carry even lower caps for eligible households. Private plans that are not ACA-compliant, such as short-term or some underwritten products, are not bound by the federal limit. They may cap costs per condition, per benefit, or not at all, so a low premium can hide a much larger worst-case number. If you are weighing private coverage, ask for the true worst-case figure in writing.
How to use this number
When comparing plans, add the yearly premium to the OOP max. That sum is your realistic worst case for in-network care. Our guide on how to read a health insurance quote shows how to line these up, and an annual health insurance plan review helps catch cap changes at renewal.
To see worst-case totals side by side for your situation, start a quote request.
Common questions
Do premiums count toward the out-of-pocket maximum?
No. Premiums are what you pay to keep the coverage active. Only cost sharing for covered care, such as deductibles, coinsurance and copays, counts toward the cap.
Does out-of-network care count toward my cap?
On most HMO and EPO plans, out-of-network care is not covered at all except emergencies. PPO plans often have a separate, higher out-of-network maximum, and some have no cap for out-of-network care.
Why did my out-of-pocket maximum go up for 2027?
The federal ceiling rose to $12,000 self-only and $24,000 family for 2027, and plans often adjust their caps along with it. Review your renewal notice before open enrollment.
Related terms
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