Questions & answers · Health insurance
What is an out-of-pocket maximum and what does it not include?
Health insuranceWho paysChecked Nov 6, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: HealthCare.gov · Out-of-pocket maximum/limit · Glossary View original ↗
In short
- It is the most you pay for covered services in a plan year.
- After you reach it, your plan pays 100% of covered in-network care.
- Premiums and out-of-network costs don't count.
What this means
HealthCare.gov says the out-of-pocket maximum is the most you pay for covered services in a plan year. Once you reach it, your plan pays 100% of covered in-network care. What counts toward it: deductibles, copays and coinsurance for in-network care [1].
It does not include your monthly premiums. It does not include 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 one person or $21,200 for a family [1]. The page also lists higher limits for 2027 [1].
Your next step
Check your plan's out-of-pocket maximum against the Marketplace limits above [1]. The sources give no deadline.
Check it yourself
The sources here give the Marketplace limits only. Your own plan papers show your plan's limit — "Don't know yet" here.
Where this comes from (1)
[1] HealthCare.gov · Out-of-pocket maximum/limit · Glossary · checked 2026-11-06
The most you have to pay for covered services in a plan year … your health plan pays 100% of the costs of covered benefits … The out-of-pocket limit doesn't include … Out-of-network care and services Costs above the allowed amount for a service that a provider may charge … 2026: No more than $10,600 for an individual or $21,200 for a family … After you spend this amount on deductibles How much you'll pay for certain …
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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