What Is an Out-of-Pocket Maximum?

The spending cap that protects you

The out-of-pocket maximum is the most you will pay for covered in-network care in a plan year. Once you hit it through deductibles, copays, and coinsurance, the plan pays 100% of covered costs for the rest of the year.

Premiums do not count toward the maximum. Neither do most out-of-network charges or non-covered services. That is why comparing only premiums can mislead you — a cheap plan with a high out-of-pocket maximum can cost more in a bad year.

How to use it when comparing plans

If you expect significant care — pregnancy, surgery, chronic specialty drugs — prioritize a lower out-of-pocket maximum even if the premium is higher. Healthy people who rarely use care may prefer the reverse.

Marketplace metal tiers roughly trade premium for cost-sharing: Bronze plans usually have higher out-of-pocket maximums; Gold and Platinum usually have lower ones. Silver plans matter for people who qualify for cost-sharing reductions.

Frequently asked questions

Does the deductible count toward the out-of-pocket maximum?

Yes. Deductible, copays, and coinsurance for covered in-network care generally count toward your out-of-pocket maximum.

What happens after I hit the maximum?

For the rest of the plan year, the plan pays 100% of covered in-network services. You still pay the premium.