This content is for general informational purposes and does not constitute medical, legal, or financial advice. Healthcare rules and costs change annually. Last reviewed: January 1, 2025. Always verify current details with your insurer, employer, or a licensed healthcare navigator.
Out-of-Pocket Maximum
The most you'll ever pay in a plan year for covered services.
Full Definition
The out-of-pocket maximum (or out-of-pocket limit) is the cap on what you pay in a plan year for covered in-network services. Once you reach it — through deductibles, copays, and coinsurance — your insurer pays 100% of covered in-network costs for the rest of the year. ACA plans have federally mandated out-of-pocket maximums.
Real-World Example
Your out-of-pocket max is $6,000. After a hospital stay, your combined deductible, copays, and coinsurance total $6,000. Your remaining medical bills that year are fully covered by your insurer.
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