Out-of-Pocket Maximum
The most you pay for covered healthcare services in a plan year before your insurer covers 100% of further costs.
What is Out-of-Pocket Max?
The out-of-pocket maximum (or out-of-pocket limit) is the maximum dollar amount a health insurance policyholder pays for covered in-network healthcare services in a plan year. After reaching this cap, the insurer pays 100% of covered in-network costs for the remainder of the year. Amounts that count toward the out-of-pocket maximum include deductibles, copayments, and coinsurance for covered in-network services. Premiums, out-of-network costs (for non-emergency care), and services not covered by the plan do not count toward the cap. For 2024, the ACA caps individual out-of-pocket maximums at $9,450 and family maximums at $18,900 for plans sold on the marketplace. The out-of-pocket maximum is distinct from a deductible: the deductible must be met before the insurer begins cost-sharing, while the out-of-pocket maximum is the total ceiling on what you pay.
Example
A policyholder with a $1,500 deductible, 20% coinsurance, and a $6,000 out-of-pocket maximum is diagnosed with cancer requiring $80,000 in treatments. She pays the $1,500 deductible, then 20% coinsurance until her total out-of-pocket spending reaches $6,000. After that, her insurer covers 100% of remaining in-network treatment costs for the year.