Health insurance has a lot of numbers. The out-of-pocket maximum may be the most important one. It sets a ceiling on what you pay for covered care in a year.
This guide explains what counts toward it, how it works with your deductible, how family limits work, and the federal caps for 2027.
What an out-of-pocket maximum is
Federal rules call it the annual limitation on cost sharing (45 CFR 156.130). Cost sharing is what you pay when you get care. Under 45 CFR 155.20, it includes:
- Your deductible: what you pay before the plan starts to share costs.
- Copays: a set amount, like $30 for a visit.
- Coinsurance: a share of the cost, like 20%.
Once your deductibles, copays, and coinsurance for covered care reach your plan's limit, you stop paying for covered in-network care for the rest of the plan year. The plan pays the full allowed amount.
What counts, and what doesn't
The same rule (45 CFR 155.20) says cost sharing does not include premiums, balance billing from out-of-network providers, or spending on care the plan doesn't cover. So these usually don't count toward your out-of-pocket maximum:
- Your monthly premium. You keep paying it all year.
- Out-of-network care. In plans with a network, what you pay out of network doesn't have to count (45 CFR 156.130(c)).
- Care your plan doesn't cover.
- Extra charges above what the plan allows, sometimes called balance bills.
Each plan's papers list exactly what counts. Check the Summary of Benefits and Coverage before you enroll.
Deductible vs. out-of-pocket maximum: an example
Your deductible is what you pay first. Your out-of-pocket maximum is the most you pay in total. Copays and coinsurance count toward both in most plans, but check your own plan.
Example, with made-up round numbers: your plan has a $2,000 deductible, 20% coinsurance, and a $5,000 out-of-pocket maximum. You have a $30,000 in-network hospital stay that the plan covers. You pay the first $2,000 (your deductible). Then you pay 20% of the rest. 20% of $28,000 would be $5,600, but you only pay $3,000 more, because that brings you to your $5,000 limit. The plan pays the rest of the bill and any covered in-network care for the rest of the year. Your premiums are extra.
To compare plans using these numbers and more, see our guide on how to compare health insurance plans.
The 2027 federal caps
Every year, CMS sets the highest out-of-pocket maximum an ACA plan can have. As of October 17, 2026, under current law, CMS guidance from January 29, 2026, sets the 2027 caps at:
- $12,000 for self-only coverage (one person).
- $24,000 for other than self-only coverage (a family plan).
These are the highest limits allowed, not what every plan uses. Many plans have lower limits. For 2026, the caps were $10,600 and $21,200.
A newer rule (45 CFR 156.136) would have allowed one exception for plan years starting in 2027. It would have let some insurance companies offer individual-market Bronze plans with a higher limit, up to 130% of the federal cap. As of October 17, 2026, a federal court has paused that rule while a lawsuit continues, so it is not in effect. The limit on every plan is listed in its plan summary.
Federal law also applies the cap to most job-based plans (42 U.S.C. 300gg-6(b)).
Family plans and the embedded limit
A family plan has two limits. There's a family limit for everyone together. There's also a limit for each person.
When HHS set the 2016 rules (80 FR 10750), it said the one-person cap applies to each person, even in a family plan. So for 2027, no one person in a family plan pays more than $12,000 for covered in-network care, even if the family limit is $24,000.
Picking a plan for your family? See our post on family health insurance mistakes.
Lower limits on some Silver plans
If your income is low enough, you may qualify for cost-sharing reductions. These lower your out-of-pocket maximum, your deductible, and other costs. Most people can get them only on a Silver plan bought through the Marketplace (45 CFR 156.420). CMS notes separate rules for American Indian and Alaska Native enrollees.
For 2027, CMS set these lower out-of-pocket maximums, based on your household income for the year you are covered:
- 100% to 150% of the poverty line: $4,000 for one person, $8,000 for a family.
- Over 150% to 200%: $4,000 for one person, $8,000 for a family.
- Over 200% to 250%: $9,600 for one person, $19,200 for a family.
Not sure what your income will be? See how to estimate your income for Marketplace insurance. For help picking a metal level, see our Florida guide.
Plans that aren't ACA plans
These federal caps are for ACA plans. Short-term plans are not ACA plans, so the caps don't apply to them. Some people look at other private plans sold outside the Marketplace. Some private plans ask health questions, and approval is not guaranteed. Some may not cover care for health problems you had before you enrolled. Some plans use PPO networks in many states. Check each plan's out-of-pocket limit in its papers. See our page on nationwide private PPO health insurance.
How we can help
Daniels Health Advisors is licensed in 30+ U.S. states. We can help you compare out-of-pocket limits across plans. Try our Policy Pricing Calculator for a rough first look.