An out-of-pocket maximum (OOPM) is the most you'll pay for covered in-network care in a plan year. Think of it as a financial safety net. Once your spending on deductibles, copayments, and coinsurance hits this limit, your plan pays 100% of covered benefits for the rest of the year. The details matter for budgeting healthcare costs and for designing better benefits.
What Counts Toward Your OOPM
These expenses usually count:
- Deductibles: The amount you pay before your plan starts sharing costs.
- Copayments (Copays): Fixed amounts (e.g., $30) for services like doctor visits or prescriptions.
- Coinsurance: Your share of the costs (e.g., 20%) after you've met your deductible.
But several key expenses are typically excluded from the OOPM:
- Your monthly premiums.
- Out-of-network care (unless your plan has a separate, often higher, OOPM for such services).
- Non-covered services (e.g., elective cosmetic surgery).
- Amounts you pay that exceed the plan's allowed amount for a service.
ACA Rules and Annual Limits
The Affordable Care Act (ACA) caps OOPMs each year. For 2026, the maximum OOPM for ACA-compliant plans is $10,600 for an individual and $21,200 for a family. The limit adjusts annually for inflation, and many employer plans set theirs lower. These caps apply only to in-network essential health benefits. Plans can have separate, often much higher, OOPMs for out-of-network care.
Family plans carry an extra rule. Since 2016, each family member retains an embedded individual cap: no single person can be required to pay more than the individual OOPM, even if the family total never reaches the family limit.
No Surprises Act: When Out-of-Network Care Still Counts
The separate out-of-network cap has an important carve-out. Starting January 1, 2022, the No Surprises Act bans balance billing for most emergency services, for non-emergency care from out-of-network providers at in-network facilities, and for out-of-network air ambulance transport. In those situations your plan must treat the care as in-network for cost-sharing purposes, so what you pay counts toward your in-network OOPM. The protection does not apply to non-emergency care you choose at an out-of-network facility.
How It Works: An Example
Say you have a plan with a $2,000 deductible, 20% coinsurance, and a $6,000 OOPM.
- You get a $10,000 surgery bill (in-network, covered).
- First, you pay the full $2,000 deductible.
- For the remaining $8,000, your 20% coinsurance means you owe $1,600.
- So far you've spent $3,600. That's below your $6,000 OOPM.
- Later, you need more treatment costing $50,000. You pay 20% coinsurance until your total hits the $6,000 OOPM. In this case, that's another $2,400.
- Once you've paid $6,000 out-of-pocket, your plan covers 100% of any further covered in-network costs for the rest of the plan year.
Why OOPMs Matter in Benefit Design
The OOPM is an important financial stopgap. It also exposes a gap: the cap limits what you pay after you get sick, and it never pushes anyone to stay well. Some plans, like WellthCare™, take a different approach. They offer $0-copay preventive care used first, before the deductible and OOPM even apply. WellthCare, the first Health-to-Wealth Benefit System, rewards every verified preventive action with spendable store dollars and automatic retirement contributions. Employees build health and wealth together while employers reduce claim costs. The idea is prevention: fewer large bills arrive in the first place, which compounds for employees and employers alike.
Tips for Employees and Employers
For Employees: Check your Summary of Benefits and Coverage (SBC) to know your plan's OOPM, what counts, and whether there are separate limits for in-network vs. out-of-network. Pair a high-deductible health plan with an HSA to save pre-tax dollars for costs up to your OOPM.
For Employers: When picking a plan, think about the OOPM alongside employee financial wellness and retention. A lower OOPM provides greater security but often comes with higher premiums. Smart strategies go beyond setting limits. They integrate systems that cut claim frequency and severity through preventive care, lowering costs and building long-term health.