Understanding out-of-pocket maximums
The ceiling on what you'll pay in a year.
Your deductible, copays, and coinsurance all feed into the same number. This guide shows how they add up, and what does — and doesn't — count.
Show me how it adds up ↓Quick recap
Your out-of-pocket maximum is the most you generally pay in a plan year for covered services subject to that limit. Need the basics? See the full breakdown → — this page shows how everything adds up to that number.
How your spending accumulates
Example only — a $6,000 out-of-pocket maximum, partway through the year.
Once you reach it
Your plan generally pays 100% of covered costs for the rest of the plan year — one of the few genuinely predictable moments in health insurance.
What counts toward your maximum — and what doesn't
- Deductible payments
- Copays
- Coinsurance
- Your monthly premium
- Costs for non-covered services
- Amounts above the "allowed" rate (balance bills)
Out-of-network spending may use a separate maximum
Or no maximum at all
Some plans track a separate, higher out-of-network out-of-pocket maximum — and a few don't cap out-of-network costs at all. See how network status affects your costs →
Where patients get tripped up
"My premium counts toward my max."
It generally doesn't — only cost-sharing payments for covered care count.
"Once I hit my deductible, I've hit my max."
These are different numbers — coinsurance and copays generally continue after the deductible, until the max is reached.
"My out-of-network spending counts the same way."
Not always — check whether your plan uses a separate, often higher, out-of-network maximum.
"My family max is exactly 2x my individual one."
Not necessarily — family structures vary by plan, similar to family deductibles.
In Canada? Out-of-pocket maximums mostly apply to a different layer of coverage.
Jump to the Canadian guide ↓Mostly a private-plan concept
For core medically necessary doctor and hospital care, provincial/territorial public health insurance generally doesn't use an out-of-pocket maximum in this sense, since there's typically no cost-sharing to accumulate. Out-of-pocket maximums are more relevant on the private or workplace benefits layer, capping what you pay for things like drugs, dental, or vision in a year.
What are you trying to do?
Common questions about out-of-pocket maximums
Does my out-of-pocket maximum reset every year?
Generally yes, at the start of each new plan year — similar to your deductible.
Is there a legal limit on how high my maximum can be?
Many ACA-compliant plans are subject to a federally set annual limit that can change year to year — check your current plan documents for your specific cap rather than assuming a number.
Can I track my progress toward my maximum?
Generally yes — your insurer's member portal usually shows a running total, similar to your deductible tracker.
What happens to my premium once I hit my maximum?
It continues as normal — reaching your out-of-pocket maximum doesn't affect your premium, which is a separate, ongoing cost.
Know your ceiling. Track your progress.
Understanding how everything adds up helps you anticipate your costs for the rest of the year.