Health Insurance
Out-of-Pocket Maximum
Once you hit your out-of-pocket maximum, your insurer pays all covered in-network claims for the rest of the plan year — protecting you from catastrophic medical debt.
Last reviewed: May 2026 · Editorial methodology
Definition
The out-of-pocket maximum (OOPM) is the annual cap on the total amount an enrollee must pay in deductibles, copays, and coinsurance for covered services before the insurance company pays 100% of covered in-network costs for the remainder of the plan year. For 2026, the ACA-mandated OOPM ceiling for individual coverage is $9,450 and $18,900 for family coverage on marketplace and fully insured employer plans. Premiums do not count toward the OOPM. Balance-billed amounts from out-of-network providers generally do not count either, which is why in-network care is so important. Some plans have lower OOPMs than the federal maximum, and plans with CSRs can significantly reduce the OOPM for eligible Silver plan enrollees. Family plans use an embedded or aggregate OOPM structure: embedded OOPMs mean each family member's expenses are capped individually at the self-only amount; aggregate OOPMs means the family's collective spending triggers the cap. Understanding which structure applies is important when evaluating plans for large families with mixed health needs.
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Cover Forge USA Editorial Team
Editorial Lead
This article was researched and written by the Cover Forge USA editorial team against federal sources (NAIC, CMS, FEMA, DOL, SSA, state DOIs) and standard policy forms. Bylines organize content by topic — they do not assert individual licensure. See our editorial-policy for details.
Reviewed 2026-06-14
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