What Counts Toward Your Out-of-Pocket Maximum?
Payments that typically count include your deductible, copays, and coinsurance for covered in-network services. What usually does not count: premiums, out-of-network costs on non-EPO plans, and costs for non-covered services. ACA-compliant plans must apply all cost-sharing for essential health benefits toward the out-of-pocket maximum, but plan structures vary.
How Is the Out-of-Pocket Maximum Different From the Deductible?
Your deductible is what you pay before cost-sharing begins. The out-of-pocket maximum is the total ceiling on all your cost-sharing for the year. Think of it as two milestones: hitting your deductible means your insurer starts sharing costs, and hitting your out-of-pocket maximum means your insurer covers everything after that point for covered services.
Does the Out-of-Pocket Maximum Reset Every Year?
Yes. Out-of-pocket maximums reset at the start of each new plan year, typically January 1 for calendar-year plans. If you have a costly medical event late in the year, you could hit your maximum and then have it reset shortly after, meaning significant expenses again early in the new year. Timing elective procedures can sometimes help manage this.
Frequently asked questions
Are there separate out-of-pocket maximums for families?
Yes. Family plans typically have both individual and family out-of-pocket maximums. If one family member reaches their individual limit, the insurer covers 100% of that person's costs. Once the family total reaches the family limit, all members are covered at 100% regardless of individual amounts paid.
What is the ACA limit on out-of-pocket maximums?
The ACA sets annual limits that adjust each year for inflation. For 2026, these limits are set by federal guidelines and apply to all non-grandfathered plans. Plans sold on the marketplace cannot exceed these limits, providing a federal floor of consumer protection.