What is the maximum out-of-pocket cost for an individual and what happens when I reach it?

For Marketplace plans and other non-grandfathered health plans, the maximum out-of-pocket limit for 2026 is $10,600 for an individual plan and $21,200 for a family plan. For 2027 plans, the limit rises to $12,000 for an individual and $24,000 for a family. Many plans have lower out-of-pocket maximums. See What are the 2027 Out-of-Pocket Maximum Limits? for more detail.

Once you reach your maximum, your insurance company pays 100 percent of your covered essential health benefits from in-network providers. This limit must include deductibles, coinsurance, copayments, or similar charges and any other qualified medical expenses. It does not include premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.