Glossary
Out-of-Pocket Maximum
The most you have to pay for covered health services in a plan year. After you reach this amount, your insurance pays 100% of covered services.
Last updated: May 11, 2026
The out-of-pocket maximum (sometimes called MOOP or OOP max) is the most you have to pay for covered health services in a plan year. After you reach this amount, your insurance pays 100% of covered services for the rest of the year.
This is the most important number on a plan — it is your worst-case scenario in dollars. Two plans can have similar premiums but very different out-of-pocket maximums, and that difference can be thousands of dollars if something goes wrong.
2026 federal cap
The ACA caps the out-of-pocket maximum at:
- $10,600 for individual coverage
- $21,200 for family coverage
No Marketplace plan can have an out-of-pocket maximum higher than these caps. Many plans set theirs lower.
What counts toward the out-of-pocket maximum
- Your deductible payments
- Your copays for in-network care
- Your coinsurance for in-network care
- Most prescription drug costs for covered drugs
What does NOT count
- Your monthly premium
- Out-of-network costs (in many plans)
- Services the plan does not cover (cosmetic surgery, etc.)
- Charges over the “reasonable and customary” amount on some out-of-network claims
Example
You have a Silver plan with a $3,000 deductible, 30% coinsurance, and a $7,500 out-of-pocket maximum.
- You have $50,000 in covered medical bills.
- You pay your $3,000 deductible.
- You pay 30% coinsurance on the next $15,000 = $4,500.
- Total paid so far: $7,500. You have hit the OOP max.
- The plan pays 100% of the remaining $32,000.
Out-of-pocket maximum by metal tier (typical for 2026)
| Tier | Typical OOP max single |
|---|---|
| Bronze | $8,000-$10,600 |
| Silver | $6,000-$10,600 (much lower with CSR) |
| Gold | $5,000-$8,000 |
| Platinum | $3,000-$6,000 |
Cost-Sharing Reduction on Silver can drop the out-of-pocket maximum dramatically — to as low as $3,000 for the strongest CSR tier.
Why this matters more than the deductible
If you only get sick once and need a single surgery, the deductible is the number that matters. But if you have a chronic condition, multiple specialists, ongoing prescriptions, or a catastrophic event, you blow past the deductible and the out-of-pocket maximum is your real worst case. Comparing only deductibles can miss this.
Family vs. individual out-of-pocket maximum
If you have family coverage:
- Each family member has an individual out-of-pocket maximum (capped at the individual cap)
- The family as a whole has a family out-of-pocket maximum
Once one person hits their individual cap, the plan covers 100% for that person. Once the family hits the family cap, the plan covers 100% for everyone.
Related terms
Compare out-of-pocket maximums across plans — a licensed agent will show you side-by-side worst-case scenarios.