Glossary · Costs
What is an out-of-pocket maximum?
The out-of-pocket maximum is the most you have to pay for covered services in a plan year. After you reach it through deductibles, copayments, and coinsurance for in-network care, the plan pays 100% of covered benefits.
Definition and figures from HealthCare.gov glossary, IRS Publication 969 (2025), Medicare.gov, checked October 23, 2026. This page explains the term; it does not recommend a plan.
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Out-of-pocket maximum: the facts
| Item | Fact | Source |
|---|---|---|
| Marketplace limit, 2026 | No more than $10,600 for an individual or $21,200 for a family | HealthCare.gov glossary: Out-of-pocket maximum/limit |
| Marketplace limit, 2027 | No more than $12,000 for an individual or $24,000 for a family | HealthCare.gov glossary: Out-of-pocket maximum/limit |
| Not counted | Monthly premiums, non-covered services, out-of-network care, and charges above the allowed amount | HealthCare.gov glossary: Out-of-pocket maximum/limit |
| HDHP maximum (2026) | $8,500 self-only, $17,000 family | IRS Publication 969 (2025): HSAs and other tax-favored health plans |
| Original Medicare | No yearly out-of-pocket limit unless you have supplemental coverage or a Medicare Advantage Plan | Medicare.gov: Medicare costs (2026) |
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Compare and look up
- Deductible vs Out-of-pocket maximumSide-by-side comparison
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Related terms
Questions
What does out-of-pocket maximum mean in health insurance?
The out-of-pocket maximum is the most you have to pay for covered services in a plan year. After you reach it through deductibles, copayments, and coinsurance for in-network care, the plan pays 100% of covered benefits.
Is the out-of-pocket maximum the same as the deductible?
No. The deductible is what you pay before the plan starts to pay. The out-of-pocket maximum caps your total spending on covered in-network care for the year, and the deductible counts toward it.
Does Original Medicare have an out-of-pocket maximum?
No. Medicare.gov says there is no yearly limit in Original Medicare unless you have supplemental coverage, like Medigap, or join a Medicare Advantage Plan.
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Rivvi explains the term from public CMS, Medicare.gov, and HealthCare.gov sources and works through an example with your numbers.
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