The Most Important Number in Your Health Plan
Your out-of-pocket maximum (OOP max) is the annual cap on what you pay for covered healthcare services. Once you hit this number, your insurance pays 100% of all covered costs for the rest of the plan year.
For 2025, the ACA requires that no non-grandfathered plan charge more than:
- $9,450 for individual coverage
- $18,900 for family coverage
๐ก The out-of-pocket maximum is your financial safety net. No matter how sick you get, you will not pay more than this amount for covered in-network services in a single year.
What Counts Toward Your OOP Max
For ACA-compliant plans, all of the following count toward your out-of-pocket maximum:
- Deductible payments
- Copays (for most plans)
- Coinsurance payments
What Does NOT Count Toward Your OOP Max
These costs do not count and never will โ no matter how much you spend:
- Monthly premiums โ your monthly payment is never included
- Out-of-network costs โ services from providers not in your network
- Non-covered services โ anything your plan doesn't cover
- Balance billing amounts โ in some cases, the amount above what your insurer allows
- Separate drug OOP max โ some plans have a separate OOP max for prescription drugs
How the Math Works
Say your plan has a $2,000 deductible, 20% coinsurance, and a $7,000 out-of-pocket maximum. You need a $40,000 surgery:
- You pay: $2,000 deductible
- You pay: 20% of remaining $38,000 = $7,600 โ but capped at your OOP max
- You've already paid $2,000 toward OOP max, so you pay $5,000 more in coinsurance
- Total you pay: $7,000 (your OOP max). Insurance covers everything else.
Family OOP Max โ How It Works
Family plans have both an individual OOP max and a family OOP max. Once any single family member hits their individual OOP max, insurance covers 100% of their costs โ even if the family OOP max hasn't been reached. Once the family OOP max is hit, everyone on the plan is fully covered.
Frequently Asked Questions
What happens after I meet my out-of-pocket maximum?
Once you reach your out-of-pocket maximum, your insurance pays 100% of all covered, in-network services for the remainder of that plan year. Your OOP max resets on January 1st (or your plan anniversary date).
Is the deductible part of the out-of-pocket maximum?
Yes, for ACA-compliant plans. Your deductible payments count toward your out-of-pocket maximum. So if your OOP max is $7,000 and your deductible is $2,000, you only need to pay $5,000 more in coinsurance after the deductible before hitting your maximum.
Why do some people have two out-of-pocket maximums?
Some plans have separate out-of-pocket maximums for medical services and prescription drugs. This means your drug costs accumulate in a separate tracker and don't count toward your medical OOP max. Always check your plan documents for this distinction.