An out-of-pocket maximum is the most you pay in a plan year for covered, in-network care. Your deductible, copays and coinsurance all count toward it. Once you reach it, the plan pays 100% of covered in-network care until the year resets. For 2027 coverage, ACA plans can't set it above $12,000 for one person or $24,000 for a family.
- For 2027 coverage, the federal ceiling is $12,000 for self-only coverage and $24,000 for family coverage, up from $10,600 and $21,200 in 2026.
- Your premiums never count toward the cap, and neither do services your plan doesn't cover.
- On a family plan, no single person pays more than the self-only limit, even if the family total is higher.
- Silver plans with extra savings can cut the 2027 cap to $4,000 for one person, based on income.
- Short-term and fixed-benefit plans don't have to follow these limits.
What is an out-of-pocket maximum?
In other words, think of it as the ceiling on your share of a bad year. You pay your deductible first, then copays or coinsurance. When those payments add up to the cap, you stop paying for covered in-network care. After that, the plan picks up the whole bill until the new plan year starts.
So the out-of-pocket maximum is your worst-case number. It matters most in the year you hope never comes, such as a surgery, a cancer diagnosis or a new baby. Our plain-English starter guide to coverage shows how it fits with the other plan terms.
Your next step: find the cap on your plan's Summary of Benefits and Coverage. Then compare it to what you could pay from savings if you had to.
Federal out-of-pocket maximum limits by plan year
First, federal rules set a ceiling on the cap for ACA-compliant plans. Insurers can set a lower cap, and many do. However, they can't go higher. CMS published these limits for the 2027 plan year.
| Plan or income level | Self-only cap | Family cap |
|---|---|---|
| Standard ACA plan, 2026 | $10,600 | $21,200 |
| Standard ACA plan, 2027 | $12,000 | $24,000 |
| Silver with extra savings, 100% to 200% of FPL | $4,000 | $8,000 |
| Silver with extra savings, 200% to 250% of FPL | $9,600 | $19,200 |
Who these limits apply to
The same ceiling applies to most job-based plans, too. Non-grandfathered employer plans, including self-insured ones, must follow it. Meanwhile, the lower Silver caps apply only when your income qualifies and you pick a Silver plan. You can compare metal levels in our guide to Bronze, Silver and Gold plan costs.
What counts toward your out-of-pocket maximum
In short, only your share of covered, in-network care counts. That rule sounds simple, but it trips up a lot of people. Here is the quick version.
Usually counts
- Payments toward your deductible
- Copays for covered visits and prescriptions
- Coinsurance for covered care
- Emergency care and surprise bills that federal law protects
Usually doesn't count
- Your monthly premiums
- Most care from out-of-network providers
- Services your plan doesn't cover
- Charges above the allowed amount that a provider bills you
For a full list of everyday costs, see how to estimate your yearly medical spending. Also, check whether your plan has a separate drug deductible, since rules vary.
A licensed Vivna agent can compare caps, premiums and networks across plans from 50+ carriers, at no cost to you.
How an out-of-pocket maximum works in a real year
Real numbers make this easier, so here is an example. Meet Jordan, 45, on an example plan with a $3,000 deductible, 20% coinsurance and an $8,000 cap. These figures are for illustration only, not a quote.
- February checkup
Jordan pays $0 for a preventive visit in network. So nothing counts toward the cap yet.
- May knee surgery
The network price is $45,000. First, Jordan pays the $3,000 deductible. Then 20% of the rest would be $8,400.
- Cap kicks in
Instead, Jordan stops at $8,000 total, because that is the plan's cap. The plan pays the other $37,000.
- Rest of the year
Physical therapy and follow-ups cost Jordan $0, as long as they are covered and in network.
What the meter looks like
As you can see, Jordan pays a small slice of the $45,000 bill.
Still, Jordan keeps paying premiums every month. So the true worst case is the cap plus 12 months of premiums.
How a family out-of-pocket maximum works
Family plans have two caps working at once. First, each person has an individual cap. Second, the whole household has a family cap. Since 2016, federal rules say no one person on a family plan pays more than the self-only limit.
A family example for 2027
Say a family plan has a $9,000 individual cap and an $18,000 family cap. In March, one child needs surgery and reaches $9,000. From then on, the plan pays 100% of that child's covered in-network care. Meanwhile, the parents keep paying until the household total hits $18,000.
So the family cap protects you when two or more people have a costly year. To plan a household budget, read our guide to what families pay for coverage.
Out-of-network care and the out-of-pocket limit
Out-of-network care is the biggest hole in most caps. HMO and EPO plans usually don't cover it at all, except in emergencies. As a result, those bills don't count toward your cap.
PPO plans often cover some out-of-network care. However, they may track it under a separate, higher cap, or under no cap at all. Also, a provider outside the network can bill you the difference between its charge and the allowed amount. That balance bill doesn't count either.
There is one key exception. When the No Surprises Act protects you, such as in an emergency, you pay in-network cost sharing, and it counts toward your in-network deductible and limit. Learn more about your rights when a provider is outside your plan.
Plans that don't follow the out-of-pocket maximum rules
However, not every health plan has to cap your costs. These plan types sit outside the ACA rules, so read their limits closely.
Short-term health plans are not ACA-compliant coverage. They can exclude pre-existing conditions, don't qualify for subsidies and are sold only in approved states. Also, their yearly cost limits can be far higher than ACA caps, or they may cap benefits instead of your spending.
Fixed indemnity and other supplemental plans pay set cash amounts. They don't cap your costs, but they can help you cover a deductible. Compare how short-term plans stack up against ACA coverage before you choose one.
How to compare out-of-pocket maximums
A lower cap usually means a higher premium. So the right cap depends on how much care you expect and how much cash you could cover in a hard year.
A lower cap often wins, because you will likely reach it.
A higher cap with a lower premium may cost less overall.
Check Silver plans with extra savings first, since the cap can drop to $4,000.
Look at the individual cap inside the family plan as well as the total.
Ask yourself one question: could I pay this cap from savings in a single year? If the answer is no, a plan with a lower cap may be worth the higher premium. Also, confirm your doctors are in network, because the cap only protects in-network care.
Next, see if you qualify for premium tax credits to offset a higher premium. You can also search carrier networks for your doctors, then compare ACA and private medical plans. Questions? Call 888-730-6031.
Out-of-pocket maximum: FAQs
Is the out-of-pocket maximum the same as the deductible?
No. The deductible is what you pay before your plan starts sharing costs. The cap is the most you pay in total for the year, and your deductible counts toward it. For example, a plan might have a $3,000 deductible and an $8,000 cap. You can read more about how deductibles reset and apply.
Do premiums count toward my out-of-pocket limit?
No. Premiums keep your plan active, but they sit outside the cap. Only your deductible, copays and coinsurance for covered in-network care count. So for a true worst-case budget, add 12 months of premiums to the plan's yearly cap.
What happens after I reach my out-of-pocket maximum?
Your plan pays 100% of covered in-network care for the rest of the plan year. However, you still pay your monthly premium. You also still owe for services the plan doesn't cover and for most out-of-network care. Then the cap resets when the new plan year begins, usually January 1 for individual plans.
Do copays count toward the out-of-pocket maximum?
Yes, on ACA-compliant plans, copays for covered in-network care count toward the cap. Coinsurance counts too. That is true even when a copay doesn't count toward your deductible. Our guide to flat fees and percentage costs compared explains both.
Why is my plan's cap lower than the federal limit?
The federal number is only a ceiling. Insurers can set any cap below it, and many plans do, especially at higher metal levels. Also, Silver plans with extra savings have lower caps for people who qualify by income. So two plans from the same carrier can have very different caps.
Can a licensed agent help me compare caps?
Yes. A licensed agent can line up caps, premiums and networks so you see the full cost of each plan. Vivna's agents compare plans from 50+ carriers, such as UnitedHealthcare, Ambetter and Oscar, at no cost to you. Call 888-730-6031 Monday through Friday, 9am to 6pm.
Vivna's licensed agents compare plans from 50+ carriers. Call Monday through Friday, 9am to 6pm.
Sources
- CMS: 2027 Premium Adjustment Percentage and Maximum Annual Limitation on Cost Sharing
- HealthCare.gov glossary: The most you pay for covered services
- U.S. Department of Labor: ACA FAQs Part XXVII (embedded self-only limit)
- CMS: Your rights and protections against surprise medical bills
- HealthCare.gov: Cost-sharing reductions
Vivna Insurance is a licensed, independent health insurance agency (NPN 19168641). We are not affiliated with HealthCare.gov or any government agency. Plan availability, networks and benefits vary by state and change over time. Short-term plans are available only in approved states and are not ACA-compliant coverage.
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