Do Copays Count Toward My Out-of-Pocket Maximum?

The Short Answer

For most ACA-compliant health plans, copays DO count toward your out-of-pocket maximum. This means every copay you pay — whether for a doctor visit, specialist, or urgent care — accumulates toward your annual OOP max cap.

⚠️ However, this is not universal. Some plans treat copays differently. Always check your plan's Summary of Benefits and Coverage to confirm.

Why Copays Count Toward OOP Max

The ACA requires that all cost-sharing (deductibles, copays, and coinsurance) for essential health benefits count toward the out-of-pocket maximum. This protects you from unlimited spending — once you hit the OOP max, you pay nothing more for covered in-network services.

When Copays May NOT Count

Grandfathered plans — older plans from before 2010 may have different rules
Non-essential benefits — copays for services not considered essential health benefits
Out-of-network copays — usually tracked separately or not counted at all
Separate drug OOP max — some plans have a separate drug OOP max that doesn't combine with medical

How to Check Your Plan

Find your Summary of Benefits and Coverage (SBC)
Look for the section on "Out-of-Pocket Limit"
Check whether it states copays are included in the limit
Call your insurer to confirm if anything is unclear

Practical Example

Say your OOP max is $5,000 and you've paid $4,800 through deductibles and coinsurance. You then have a $40 copay visit. You only owe $200 (the remaining OOP max) — not $40. Your insurer covers the rest.

Track Your OOP Max Progress

Use our cost calculator to see how each visit moves you toward your annual maximum.

Track Your OOP Max Progress →

Frequently Asked Questions

Do copays count toward the deductible?

Usually no. Copays are typically separate from the deductible. You pay copays from day one (before meeting your deductible), but they don't reduce your deductible balance. However, copays usually DO count toward your out-of-pocket maximum.

What is the out-of-pocket maximum for 2025?

For 2025, the ACA caps the out-of-pocket maximum at $9,450 for individual coverage and $18,900 for family coverage. No ACA-compliant plan can make you pay more than this for covered in-network services.

Do prescription copays count toward OOP max?

It depends on the plan. Many plans have separate prescription drug cost-sharing that either has its own OOP max or is integrated into the medical OOP max. Check your plan documents carefully for prescription drug treatment.