Out-of-pocket maximum
The most you'll pay in a year before insurance covers 100% of costs.
Full definition
The out-of-pocket maximum (OOPM) is the cap on what you'll pay for covered health services in a plan year. Once you reach this limit — through your deductible, copays, and coinsurance combined — your insurance covers 100% of covered services for the rest of the year. ACA plans cap OOPM at $9,450 for individuals and $18,900 for families in 2026.
Real-world example
Your OOPM is $6,500. After a hospitalization, your total out-of-pocket costs hit $6,500. Any further covered medical costs for the rest of the year are paid 100% by your insurer.
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The most you'll pay in a year before insurance covers 100% of costs.
Related terms
- Deductible
The amount you pay out of pocket before insurance kicks in.
- Health insurance deductible
The amount you pay for health care each year before insurance starts paying.