Health Insurance Out-of-Pocket Maximum

Healthcare Finance

Updated Apr 2026 • Has calculator

Total out-of-pocket medical cost after deductible and coinsurance, capped at the plan's OOP maximum.

What is Health OOP Max?

The out-of-pocket maximum (OOP max) is the most a health insurance member pays for covered services in a plan year. After meeting the deductible, the member shares costs with the insurer via coinsurance until total out-of-pocket spending reaches the OOP max, after which the insurer covers 100% of costs. Under the ACA, OOP maximums for 2026 are capped at $9,200 for individuals and $18,400 for families. This calculator estimates total patient cost for a given medical bill under a specific plan design.

Formula

OOP = min(OOP Max, Deductible + Coinsurance% × max(0, Bill − Deductible))

Worked Example

2026

Step 1 Deductible: $1,500 | Coinsurance: 20% | OOP Max: $7,000

Step 2 Medical bill: $25,000

Step 3 Without cap: $1,500 + 20% × ($25,000 − $1,500) = $6,200

Step 4 $6,200 < $7,000 OOP max → you pay $6,200

Step 5 → ACA OOP cap protects against catastrophic bills

Source: Healthcare.gov — Out-of-Pocket Maximum (2026-01-01)

Calculate Health OOP Max

Annual Deductible

Coinsurance Rate

Your share after meeting deductible

Out-of-Pocket Maximum

Total Medical Bill

Your Out-of-Pocket Cost

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Not investment advice.

How to Interpret Health OOP Max

< 1000

Minimal Cost — minor medical event covered cheaply

1000 – 3000

Moderate Cost — significant but manageable expense

3000 – 6000

High Cost — approaching OOP max; review your plan

> 6000

At OOP Max — insurer covers 100% of additional costs

📚 Insurance Planning — Complete the path

Sources