Out-of-Pocket Maximum

The most you'll ever pay for covered healthcare in a plan year — once you hit it, your insurance covers 100% of in-network costs for the rest of the year.

The out-of-pocket maximum (OOPM) is a cap on the total amount you pay for covered healthcare services in a plan year. After you've paid your deductible, copays, and coinsurance totaling the OOPM amount, your insurance covers 100% of covered in-network costs for the remainder of the year — you pay nothing more for those services. It's a financial protection against catastrophic medical costs. For 2024, the ACA-mandated maximum OOPM is $9,450 for individual coverage and $18,900 for family coverage.

Understanding the OOPM requires clarity on what counts toward it. Your monthly premiums do not count toward your OOPM. Your deductible, copays, and coinsurance for in-network covered services all count. Out-of-network costs may or may not count, depending on your plan. Non-covered services (services your plan excludes entirely) never count. For plans with both individual and family OOPM limits, the family OOPM is the aggregate: once the family collectively hits the family limit, everyone is covered at 100% regardless of individual limits.

When comparing plans during open enrollment, the OOPM is one of the most important figures to evaluate — especially if you or a family member has a chronic condition or might face significant medical costs. A plan with a low premium but a high OOPM can leave you far more exposed than a plan with a higher premium but a low OOPM. Running the 'worst case scenario' math — if you hit your OOPM, what is your total annual cost including premiums? — often reveals which plan is actually cheaper for someone with significant healthcare usage.