The out-of-pocket maximum is one of the most important health insurance terms to understand, and one of the most misunderstood. Most people assume it covers any medical spending they have. It does not.
This guide covers what counts and what doesn't count toward your OOP max, the 2026 federal limits, and how it works on family vs. individual plans. For Medicare enrollees, Medicare's cost structure works differently from the ACA OOP max framework.
Annual Out-of-Pocket Maximum Limits
| Plan Type | Individual | Family |
|---|---|---|
| ACA marketplace plan (any metal tier) | $9,200 | $18,400 |
| HSA-qualified HDHP | $8,500 | $17,000 |
Individual plans may have a lower OOP max than the federal cap. Specific plans can set an OOP max below the federal limit.
Source: HHS 2026 Notice of Benefit and Payment Parameters; IRS Rev. Proc.
What Counts Toward the Out-of-Pocket Maximum
These payments count toward your OOP max and trigger 100% coverage once you hit the limit:
- Deductibles
- Copays
- Coinsurance
- Costs for covered, in-network services
What Does NOT Count Toward the Out-of-Pocket Maximum
These charges never count toward your OOP max, even if you are paying them every month:
- Monthly premiums (important!)
- Out-of-network charges (in most plans)
- Balance billing amounts
- Services not covered by your plan
- Charges from providers outside your plan network
Example: How It Works in Practice
Consider Sarah, a single 35-year-old with a marketplace ACA Silver plan with a $9,200 OOP max. Over the year, she hits her OOP max after a hospitalization:
| Spending category | Amount |
|---|---|
| Deductible (met) | $2,500 |
| Hospitalization coinsurance | $3,000 |
| Additional coinsurance during year | $3,700 |
| Total reached | $9,200 |
| What insurance pays after | 100% rest of year |
After hitting OOP max, Sarah pays no more copays, coinsurance, or deductible costs for the rest of the plan year, but continues paying her monthly premium.
Individual vs. Family OOP Max
Family plans have two OOP maxes: the embedded individual OOP max (capped at $9,200 in 2026) that applies to any single person on the plan, and the larger family OOP max ($18,400 in 2026) that applies to combined family spending. Whichever is hit first triggers 100% coverage for that person or the family. If your income qualifies for a Silver plan with cost-sharing reductions, your actual OOP max may be substantially lower than the federal ceiling.
Why the OOP Max Matters When Choosing a Plan
The OOP max is the plan's financial protection guardrail. A cheap Bronze plan with a $9,200 OOP max could still cost you $9,200 out of pocket plus premiums in a bad year. A more expensive Gold plan with a lower OOP max may come out cheaper if you have significant medical spending. If you are chronically ill, pregnant, or know you have a major surgery coming, a lower OOP max almost always beats the cheaper premium. Procedures like an echocardiogram or colonoscopy count toward your OOP max, so understanding procedure costs helps you forecast your exposure.