What Counts Toward Your Out-of-Pocket Maximum?

Your out-of-pocket maximum is the most you pay for covered services during a plan year before your health plan pays 100% of covered costs. Deductibles, copayments, and coinsurance typically count toward that limit, while premiums and noncovered services usually don't.

The distinction matters when you're comparing health insurance plans: the maximum isn't a cap on every dollar you spend . Here's how it works and which costs can fall outside it.

Key takeaways

• Your deductible, copays, and coinsurance for covered care typically count toward your limit.
• Monthly premiums continue even after you reach the maximum.
• Out-of-network care can have different limits, or the plan may not cover it at all.
• Family coverage has a family limit and may also list individual limits for members.

What an out-of-pocket maximum covers

An out-of-pocket maximum limits your share of the cost for covered services within a plan year. Once you reach it, your insurer pays 100% of covered services for the rest of that year, subject to the plan's coverage rules.

For most comparisons, the number you'll see is the in-network maximum . It applies to covered care from doctors, hospitals, and other providers in the plan's network.

The limit resets when a new plan year begins. That means you can start accumulating deductible and other cost-sharing expenses again, even if you reached the maximum during the previous year.

HealthCare.gov's explanation of total health care costs shows how the maximum fits alongside your premium and deductible. Those figures answer different questions, so none tells you the full cost of coverage on its own.

Which costs usually count toward the maximum?

Payments for covered, in-network care generally move you closer to your limit. The amount that counts is your share under the plan's rules, rather than the provider's original bill.

Deductible payments

Your deductible is the amount you pay for covered services before your plan starts sharing the cost of many services. For example, if an in-network imaging service has an allowed cost of $1,000 and that amount applies to your deductible, the $1,000 typically also counts toward your out-of-pocket maximum.

The deductible doesn't necessarily apply to every service. A plan may cover certain preventive services without charging you or may use copays for some visits before you meet the deductible.

Copayments and coinsurance

A copayment , or copay, is a fixed amount you pay for a covered service. A specialist visit, for example, might have a $40 copay. That payment typically counts toward your maximum even if it doesn't count toward your deductible.

Coinsurance is a percentage of the covered cost. With 20% coinsurance, your share of a $1,000 allowed charge is generally $200, subject to the remaining amount before you reach your limit. HealthCare.gov describes how this percentage works in its coinsurance definition.

Covered prescription costs can count, too. Plans may use drug copays, coinsurance, or a separate prescription deductible. Our guide to prescription drug coverage explains how formularies and drug tiers affect those costs.

Which expenses usually don't count?

Some health-related spending remains your responsibility without bringing you closer to the plan's limit. That's an important distinction when you're setting a budget for a year with substantial care.

Monthly premiums

Your premium is the amount you pay to keep your coverage active. It doesn't count toward the out-of-pocket maximum, and you continue paying it after you reach the limit.

For a broad estimate of a high-cost year, add your annual premiums to the plan's in-network maximum. That still won't include expenses for noncovered care or other charges outside the limit.

Noncovered services and other charges

If a service isn't covered, what you pay for it generally doesn't count toward the maximum. The same applies when a plan excludes a particular out-of-network service.

Charges above a plan's allowed amount, sometimes called balance bills , also generally fall outside the limit. Federal protections restrict balance billing in certain circumstances, including many emergency situations. Plan exclusions and benefit limits can still leave you with costs after you've reached your maximum.

How networks affect what counts

Your plan's network affects both the price of care and which maximum your payments reach. An in-network provider has an agreement with the insurer, so covered care generally follows the plan's in-network cost-sharing rules.

A PPO commonly offers some coverage for out-of-network care. That coverage may have a separate deductible and out-of-pocket maximum, and your share can be higher. Payments applied to an out-of-network limit don't necessarily move you toward the in-network limit.

An HMO generally limits nonemergency coverage to its network. As a result, an elective visit outside the network may be entirely your responsibility and may not count toward the maximum.

Emergency care is different. Federal law generally requires covered emergency services to receive in-network cost-sharing treatment, even when you receive them at an out-of-network facility. Protections also apply to certain out-of-network providers at in-network facilities.

Our explanation of how health insurance networks work covers the differences in more detail.

How is the maximum different from a deductible?

The deductible is a threshold you reach before the plan begins sharing the cost of many covered services. The out-of-pocket maximum is the later limit that caps your share of covered costs for the plan year.

After you meet your deductible, you may still owe copays or coinsurance. Those payments typically continue to count toward the maximum. Once you reach that limit, the plan pays the covered costs for the rest of the plan year.

For example, a plan can have a $2,000 deductible and a $5,000 maximum. Reaching $2,000 doesn't mean all later care is free. It means the plan's post-deductible cost sharing begins for services subject to that deductible.

Some services work differently. A covered preventive visit may have no charge before the deductible, while a prescription or office visit may have a copay from the start.

An example of reaching the limit

Suppose your plan has a $2,000 deductible, 20% coinsurance after the deductible, and a $5,000 in-network out-of-pocket maximum. Assume each service below is covered and the listed amounts are the plan's allowed charges.

For the surgery, your first $1,000 completes the deductible. You then pay 20% of the remaining $11,000, or $2,200.

After the later care, you've reached the $5,000 maximum. The plan pays for covered in-network services for the rest of the plan year. Your monthly premium remains separate.

How individual and family limits work

A family policy typically lists a family out-of-pocket maximum and may also list an individual maximum. The individual figure relates to one covered person's expenses, while the family figure relates to covered expenses across the household.

The family maximum can be useful when more than one person needs care. Once the applicable family limit is met, the plan pays 100% of covered in-network costs for the rest of the plan year. Premiums and excluded expenses remain outside that protection.

For Marketplace plans in 2026, the maximum permitted out-of-pocket limit is $10,600 for an individual and $21,200 for a family. A plan can set lower limits. Those figures are specific to the 2026 plan year and don't describe every type of health plan. HealthCare.gov lists them in its out-of-pocket maximum definition.

When comparing health insurance options for Florida families, both the household limit and the coverage available to each person matter.

What happens after you reach your maximum?

For the rest of the plan year, you generally won't owe a deductible, copay, or coinsurance for covered in-network services. That can include covered office visits, imaging, and prescriptions.

Your coverage rules still apply, though. Reaching the maximum doesn't turn an excluded service into a covered one. It also doesn't remove requirements such as prior authorization when the plan requires it.

Your insurer's explanation of benefits, often called an EOB, shows how a claim was processed and what the plan says you owe. It's not a bill. Your provider sends the bill separately, and the plan's running total can change as additional claims are processed.

Compare plans using the full cost

A lower out-of-pocket maximum can reduce your exposure in a year when you need extensive covered care. However, a plan with a lower limit may also have a higher monthly premium. The better fit depends partly on how much care you expect to use.

Compare the annual premium and likely cost sharing for a light year, a moderate year, and a year when you reach the maximum. Then consider whether the plan covers your medications and includes the doctors and hospitals you use.

The summary of benefits and coverage lays out the plan's deductible, cost-sharing amounts, and limits. Our guide on how to choose a health insurance plan walks through those figures together.

We help people across Florida compare private health insurance and Marketplace options, including the costs that may be easy to miss when looking at premiums alone.

Frequently asked questions

Do copays count before I meet my deductible?

They typically count toward your out-of-pocket maximum when they're for covered services. A copay may not count toward the deductible itself, so the two totals can move at different rates.

Do prescription costs count toward the maximum?

Your share of a covered prescription generally counts, although the amount depends on the plan's drug benefits. A prescription that isn't covered generally doesn't count.

Does the maximum reset if I change plans?

A new plan can have a new deductible and out-of-pocket maximum. Whether any amount carries over depends on the plans' terms, so don't assume your previous balance transfers.

Focus on covered costs and total expenses

Your out-of-pocket maximum gives you a useful limit for covered care, but it doesn't include every health expense. Premiums, noncovered services, and some out-of-network charges can add to what you spend.

When you compare plans, consider the maximum alongside the premium and network . Together, they give you a clearer picture of what coverage may cost in a year when you need care.