What Counts Toward Your Out-of-Pocket Maximum? U.S. Health Plan Rules Explained
Your health insurance plan's out-of-pocket maximum is the most you will pay for covered in-network care in a plan year. Once you hit that limit, the plan pays 100 percent of covered services for the rest of the year. But not every dollar you spend on healthcare counts toward that cap.
Understanding what counts - and what does not - helps you predict when you will reach the maximum and plan your medical spending accordingly.
Estimate your out-of-pocket exposure
Model your annual cost-sharing under any U.S. health plan — deductible, copays, coinsurance, and out-of-pocket maximum.
Open Out-of-Pocket CalculatorWhat is an out-of-pocket maximum?
The out-of-pocket maximum (sometimes called the out-of-pocket limit) is the yearly ceiling on your share of costs for covered in-network services. Under the Affordable Care Act (ACA), all marketplace plans and most employer plans must set this limit.
For the 2026 plan year, the ACA sets federal maximums:
| Coverage type | 2026 ACA out-of-pocket limit |
|---|---|
| Individual (self-only) | $9,450 |
| Family | $18,900 |
Your plan's limit may be lower than the federal maximum, but it cannot be higher for ACA-compliant plans.
What counts toward the out-of-pocket maximum
These costs typically count toward your annual limit:
| Cost type | Counts toward OOP max? | Example |
|---|---|---|
| Deductible payments | ✅ Yes | $2,000 deductible for a hospital stay |
| Copays | ✅ Yes | $30 per primary care visit |
| Coinsurance | ✅ Yes | 20% coinsurance on a $5,000 procedure |
Deductible
Every dollar you pay toward your annual deductible also counts toward the out-of-pocket maximum. If your deductible is $3,000 and your OOP max is $8,000, reaching the deductible means you are already $3,000 closer to the cap.
Copays
Fixed-dollar copays for office visits, urgent care, specialist appointments, and prescriptions count toward the maximum on most plans. Some plans apply copays before the deductible is met, and those still count.
Coinsurance
After you meet the deductible, you typically share costs with the plan through coinsurance - your percentage of the bill. That coinsurance amount counts toward the out-of-pocket maximum.
What does NOT count toward the out-of-pocket maximum
Several common healthcare expenses do not count:
- Monthly premiums - the amount you pay to keep the plan active
- Out-of-network charges - costs from providers outside your plan's network (on many plans)
- Balance billing - the difference between what a provider charges and what the plan allows
- Services not covered by the plan - cosmetic procedures, experimental treatments, or excluded services
- Penalties for not following plan rules - such as skipping a referral requirement
The biggest surprise for most people is premiums. Even though premiums can be the largest monthly healthcare expense, they never reduce your distance to the out-of-pocket maximum.
Compare health plans side by side
See how deductible, copay, and coinsurance structure changes total cost across different plan options.
Open Health Plan Comparison CalculatorWhat happens after you hit the out-of-pocket maximum
Once your qualifying costs reach the limit, the plan covers 100 percent of remaining covered in-network services for the rest of the plan year. You still pay premiums, but you owe nothing more for covered care.
This reset happens each plan year, so the count starts over on January 1 (or the plan's renewal date).
Strategies to manage out-of-pocket costs
If you expect significant medical expenses this year, plan ahead:
- Front-load elective procedures - schedule planned care early so post-max months are fully covered
- Use in-network providers - out-of-network costs often do not count toward the maximum
- Track spending - check your explanation of benefits (EOB) to see how close you are to the limit
- Use an HSA or FSA - pay qualifying costs with pre-tax dollars for additional savings; see the HSA calculator for contribution planning
- Compare plans during open enrollment - a plan with a lower OOP max may save money in a high-use year even if the premium is slightly higher
For broader medical expense planning, use the Medical Expense Calculator and visit the health calculators hub.
For related reading, see the health plan comparison guide, the health insurance cost guide, and the HSA savings guide.
Model your expected and worst-case year
See what you may owe under a normal year vs. a high-use year with the out-of-pocket calculator.
Estimate Out-of-Pocket CostsFAQ
Does the deductible count toward the out-of-pocket maximum?
Yes. Every dollar you pay toward your annual deductible counts toward the out-of-pocket maximum. Once both the deductible and OOP max are met, the plan pays 100 percent of covered in-network care.
Do copays count toward the out-of-pocket maximum?
Yes. Copays for office visits, specialists, urgent care, and prescriptions count toward the out-of-pocket maximum on most ACA-compliant plans.
Do monthly premiums count toward the out-of-pocket maximum?
No. Monthly premiums are not included in the out-of-pocket maximum calculation. They keep your coverage active but do not reduce your remaining distance to the cap.
Does out-of-network care count toward the out-of-pocket maximum?
It depends on the plan. Many HMO and narrow-network plans do not count out-of-network costs toward the in-network OOP max. Some PPO plans have a separate, higher out-of-network maximum. Always check your plan's summary of benefits.
What is the difference between a deductible and an out-of-pocket maximum?
The deductible is the amount you pay before the plan starts sharing costs through coinsurance. The out-of-pocket maximum is the total cap on what you pay for covered in-network care in a year. The deductible is a subset - it counts toward the OOP max, but the OOP max also includes copays and coinsurance.