Questions & answers · Health insurance
I already paid a lot this year. Why is my plan still billing me, and what is the out-of-pocket maximum?
Health insuranceWho paysChecked Nov 6, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: HealthCare.gov View original ↗
In short
- The out-of-pocket maximum is the most you pay for covered care in a plan year.
- After that, your plan pays 100% of covered in-network care.
- Premiums, non-covered services and out-of-network care don't count.
What this means
HealthCare.gov defines the out-of-pocket maximum as the most you have to pay for covered services in a plan year [1]. After you spend that amount on deductibles, copayments and coinsurance for in-network care, your health plan pays 100% of the costs of covered benefits [1].
The limit doesn't include your monthly premiums, anything you spend on services your plan doesn't cover, out-of-network care, or costs above the allowed amount for a service [1]. For a Marketplace plan in 2026 the limit is no more than $10,600 for an individual or $21,200 for a family [1].
Your next step
Compare your plan's explanation of benefits (EOB) with the amounts you paid, and ask the plan in writing to total what counts toward the limit. If you think you passed it and were still billed, ask the plan to re-process the claim. The sources give no deadline.
Check it yourself
Open HealthCare.gov, Out-of-pocket maximum/limit, at https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/ and read the part quoted above. Your own plan or policy papers hold details these sources do not give: "Don't know yet" for your case.
Where this comes from (1)
[1] HealthCare.gov · checked 2026-11-06
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles How much you'll pay for certain covered services and items each year before your plan starts to pay (except free preventive services). Refer to glossary for more details. , copayments A fixed amount you pay for a plan-covered service, like $30. Refer to glossary for more details. , and coinsurance A percentage of …
How we found this
We matched your question to 1 official source, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.
What we don’t know yet
Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.
Every answer is checked against the official rule it quotes.
Information only — not legal advice. Your plan, insurer or agency decides.
This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.
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