Out-of-Pocket Maximum

How It Works

The out-of-pocket maximum (or out-of-pocket limit) protects patients from catastrophic medical costs. The ACA limits out-of-pocket maximums for marketplace plans (in 2025, $9,200 for individuals and $18,400 for families). Employer plans may have different limits. Out-of-pocket maximums include deductibles, copays, and coinsurance — but typically exclude premiums, out-of-network charges, and services not covered by the plan. For patients facing major surgery or a long hospital stay, understanding the out-of-pocket maximum is critical: once you hit it, all additional covered care is free for the rest of the year.

Related Terms

• Deductible (Health Insurance) — The amount you must pay for healthcare services before your insurance begins to pay — ranging from $0 for some plans to $7,000+ for high-deductible plans.
• Surprise Medical Bill (Balance Billing) — An unexpected bill from an out-of-network provider — often occurring during emergencies or when an in-network hospital uses out-of-network specialists without the patient's knowledge.