What Costs Count Toward my Out-of-pocket Maximum?

Your costs that contribute to your out-of-pocket maximum limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.

For 2026, the maximum out-of-pocket expenses for individual plans for in-network services are:

• Individuals: $10,600 Out-of-Pocket Maximum
• Family: $21,200 Out-of-Pocket Maximum

Like the deductible, the out-of-pocket maximum applies to the calendar year (January 1st - December 31st) and is not prorated if your plan starts in the middle of the year or if you change plans during the Special Enrollment Period.

For plan years beginning in 2027, the OOP limits will be $12,000 for self-only coverage and $24,000 for other than self-only coverage. This represents an increase of $1,400 for self-only coverage and $2,800 for other than self-only coverage over the 2026 OOP maximums of $10,600 and $21,200 respectively.