What Is an Out-of-Pocket Maximum?

The out-of-pocket maximum (OOP max) is the annual cap on how much you pay for covered healthcare services. Once you reach this limit, your insurance pays 100% of covered in-network costs for the rest of the plan year.

For 2025, ACA-compliant plans cannot exceed: $9,450 individual / $18,900 family.

What Counts Toward OOP Max

• Deductible payments ✅
• Copays (for most plans) ✅
• Coinsurance payments ✅

What Does NOT Count

• Monthly premiums ❌
• Out-of-network costs ❌
• Non-covered services ❌