What is an out-of-pocket maximum?
Your out-of-pocket maximum is the safety net that caps your spending. Learn what counts, what doesn't, and how family vs. individual limits work.
The out-of-pocket maximum (OOPM) is the most you'll pay in a plan year for covered, in-network services. Once you hit it, the plan pays 100% of covered services for the rest of the year. It's the most important number on your plan for protecting you from catastrophic bills.
What counts toward your OOPM
- Your deductible payments.
- Copays for office visits, prescriptions, ER visits, etc.
- Coinsurance amounts on covered services.
- All in-network, covered care for medically necessary services.
What doesn't count
- Your monthly premium.
- Services your plan doesn't cover (cosmetic procedures, most adult dental, etc.).
- Out-of-network charges on most plans (PPOs sometimes count a portion).
- Amounts above the plan's 'allowed amount' for a service (balance bills).
Individual vs. family OOPM
- Each family member has an individual limit
If one person on a family plan hits the individual OOPM (commonly $9,200 in 2026), the plan covers 100% of their covered services — even if the family limit hasn't been met.
- The family limit caps the total
Once the family's combined spending hits the family OOPM (commonly $18,400 in 2026), the plan covers 100% for everyone on the plan, regardless of individual limits.
- Both limits apply at the same time
An individual will hit whichever limit comes first. This is called the 'embedded' OOPM and is required by the ACA for most plans.
FAQ
- Does the OOPM reset every year?
Yes — it resets at the start of each plan year, which for most plans is January 1.
- Are dental and vision OOPMs separate?
Yes. Dental and vision plans usually have their own annual maximums (often called annual benefits maximums) and don't share with your medical OOPM.
- Why is the federal OOPM limit different from my plan's?
The federal limit is a ceiling — plans cannot set the OOPM higher than that amount, but they can (and often do) set it lower.