The out-of-pocket maximum is the most you will ever pay for covered health services in a plan year. Once you reach it, your insurer pays 100% of covered costs for the rest of the year. For 2024, ACA marketplace plans cap out-of-pocket maximums at $9,450 (self-only) or $18,900 (family).
The out-of-pocket maximum (also called the out-of-pocket limit) is your annual financial safety net. It is the most you can be required to pay in a single plan year for covered health services through deductibles, copays, and coinsurance combined. Once you hit this limit, your health insurer pays 100% of the cost for covered services through the end of the plan year. The ACA requires all marketplace plans to have an out-of-pocket maximum. HealthCare.gov's glossary covers how it applies.
For 2024, the ACA out-of-pocket maximum for marketplace plans is $9,450 for self-only coverage and $18,900 for a family. These limits apply to in-network covered services only. Out-of-network services may have separate (higher) limits or no limit, depending on your plan type — check your plan's Summary of Benefits and Coverage (SBC).
Family plans may be structured as embedded (each individual has their own out-of-pocket limit, and the family as a whole also has a limit) or aggregate (the family pool must meet the full family limit before any individual gets 100% coverage). Most ACA marketplace family plans use an embedded structure — verify in your plan's Summary of Benefits.
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