Out-of-Pocket Maximum
An out-of-pocket maximum is the most you pay for covered in-network care in an insurance plan year. It includes costs like your deductible, copays, and coinsurance. After you reach that limit, your health insurance plan usually pays 100% of covered in-network services for the rest of the year. This limit helps protect you from very high health care costs.
Last updated: September, 2026
Key Takeaways
- An out-of-pocket maximum is the most you pay for covered in-network care in an insurance plan year.
- It includes your deductible, copays, and coinsurance but not monthly premiums.
- Monthly premiums do not usually count toward the out-of-pocket maximum.
- After you reach the limit, your insurance plan usually pays 100% of covered in-network services.
- This limit can help protect you from very high health care costs and make your total risk more predictable.
What is an Out-of-Pocket Maximum?
An out-of-pocket maximum is a yearly limit on what you pay for covered in-network health care under your insurance plan. It is a financial limit built into your health plan. Costs that usually count toward it include your deductible, copays, and coinsurance.
After you reach that limit, your health plan usually pays 100% of covered in-network services for the rest of the year. Your monthly premium usually does not count toward this amount. Costs for non-covered services or some out-of-network care also may not count, such as:
- Cosmetic procedures
- Experimental treatments
- Care that is not considered medically necessary
Checking your coverage details can help you understand what counts and what does not.
How Does Out-of-Pocket Maximum Work?
Let’s say your out-of-pocket maximum is $5,000. Earlier in the year, you already paid $1,500 toward your deductible, $700 in copays, and $1,800 in coinsurance. That brings your total to $4,000.
Later, you have a hospital visit and pay another $1,000 in covered in-network costs. That brings you to your $5,000 out-of-pocket maximum. After that, your insurance plan usually pays 100% of covered in-network services for the rest of the insurance plan year.
Out-of-Pocket Maximum Example | Amount |
|---|---|
Yearly out-of-pocket maximum | $5,000 |
Deductible paid so far | $1,500 |
Copays paid so far | $700 |
Coinsurance paid so far | $1,800 |
Total before next service | $4,000 |
Next covered in-network cost | $1,000 |
Total after service | $5,000 |
How an Out-of-Pocket Maximum Affects What You Pay
An out-of-pocket maximum helps protect you from very high health care costs during the year. If you need a lot of care, this limit can keep your covered in-network costs from rising without end. That can make your financial risk more predictable.
Health insurance plans with lower monthly premiums may have higher out-of-pocket maximums. Insurance plans with higher premiums may have lower limits. That is why it helps to compare both your monthly premium and your out-of-pocket maximum when you pick a health insurance plan.
Where to Find This in Your Plan Details
To check your out-of-pocket maximum, you can look at:
- Your Summary of Benefits and Coverage (SBC)
- Your Schedule of Benefits
- Your member handbook or policy documents
- Your health plan’s website, your Ambetter Health online member account, or the mobile app.
These resources can help you check what counts toward the limit and whether different rules apply for in-network or out-of-network care.
How This Changes Across Marketplace Plans
Out-of-pocket maximums can be different across Marketplace health insurance plans. This limit is one of the most important numbers to compare because it shows the most you could pay in a worst-case year.
The amount you pay depends on the health plan category, network rules, and how cost sharing is set up. These factors work together to affect both your monthly costs and what you pay when you need care.
- Lower-premium insurance plans often have higher out-of-pocket maximums, which means more risk if you need a lot of care.
- Higher premium insurance plans may have lower limits, which can offer more predictable costs during the year.
- In-network and out-of-network rules can affect how quickly you reach your limit and what counts toward it.
- Comparing the out-of-pocket maximum with your deductible and monthly premium can help you understand your total potential costs.
FAQs About Out-of-Pocket Maximum
Costs that usually count include your deductible, copays, and coinsurance for covered in-network care. These are the amounts you pay when you receive covered services during the year. Your insurance plan documents can show exactly what counts. Monthly premiums usually do not count.
Your deductible is the amount you pay before your insurance plan starts sharing certain costs. Your out-of-pocket maximum is the most you pay for covered in-network care during the year. After you reach that limit, your insurance plan usually pays 100% of covered in-network services.
Usually, no. Monthly premiums are separate from the costs that count toward this limit. The out-of-pocket maximum tracks what you pay when you receive covered care, not what you pay each month to keep your coverage.
After you reach the limit, your insurance plan usually pays 100% of covered in-network services for the rest of the insurance plan year. This means you will not pay additional deductibles, copays, or coinsurance for covered in-network care. You may still have costs for non-covered services or some out-of-network care.
Usually, no. For most Marketplace health insurance plans, only covered services from in-network providers count toward your out-of-pocket maximum.
Out-of-network costs usually do not count, which means you could pay more if you go outside your plan’s network. Some insurance plans may have separate limits for out-of-network care or special rules for emergency services, so it is important to check your plan details before you get care.
Most Marketplace health insurance plans have an out-of-pocket maximum for covered in-network care. This limit is required for ACA-compliant plans and helps protect you from very high medical costs. Some plans outside the Marketplace may have different rules, so it is important to check your plan details.
An individual out-of-pocket maximum is the most one person pays during the year, while a family out-of-pocket maximum is the combined limit for everyone on the same plan. Once one person reaches the individual limit, their covered in-network care is usually paid at 100% for the rest of the year. Once the family limit is reached, the plan usually pays 100% for covered in-network care for all covered members.
It depends on how often you use health care. Many people do not reach their out-of-pocket maximum in a typical year, but it can happen if you need frequent care, have a major illness, or require surgery. This limit is there to protect you from very high costs if your health care needs increase.
Related Terms
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What Is Cost Sharing in Health Insurance?
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Learn MoreHave Questions About How This Works with Your Ambetter Health Plan?
Already covered? Your benefits vary by plan and location. Limitations and exclusions may apply. Contact Ambetter Health or call Member Services at the number on the back of your Member ID Card for answers specific to your coverage.
Not yet a member? Our licensed agents are ready to help you find the perfect plan. Call 855-680-3270 (TTY: 711), Monday-Friday 8 a.m. to 9 p.m. ET, to discuss your health insurance options.
Sources:
Healthcare.gov - Out-of-Pocket Maximum/Limit
Healthcare.gov - How to Pick a Health Insurance Plan