Qualifying
What is an out-of-pocket maximum in health insurance?
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 plan year 2026, ACA marketplace plans cap out-of-pocket maximums at $10,150 (self-only) or $20,300 (family), per HHS's Notice of Benefit and Payment Parameters.
The full picture
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.
2026 ACA limits
For plan year 2026, the ACA out-of-pocket maximum for marketplace plans is $10,150 for self-only coverage and $20,300 for a family — up from $9,200 and $18,400 in 2025. HHS publishes this figure annually in its Notice of Benefit and Payment Parameters, and it has risen almost every year since the ACA's cost-sharing limits took effect. 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).
What counts toward the out-of-pocket maximum
- Your deductible payments.
- Copays for covered services.
- Coinsurance for covered services.
- Note: Monthly premiums do NOT count toward the out-of-pocket maximum.
- Balance-billing charges from out-of-network providers also do NOT count.
Family plans: embedded vs. aggregate
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.
◆ ClearValue editorial analysis
The ACA cap isn't the only out-of-pocket number that matters
The ACA's marketplace-wide out-of-pocket maximum ($10,150 self-only / $20,300 family for 2026) is a ceiling that applies to every ACA-compliant plan, including high-deductible health plans (HDHPs). But if you're on an HSA-eligible HDHP specifically, a second, lower cap applies: the IRS sets a separate 2026 out-of-pocket maximum of $8,500 for self-only HDHP coverage and $17,000 for family HDHP coverage under Revenue Procedure 2025-19 — roughly $1,650–$3,300 tighter than the general ACA cap.
The practical implication: a bronze or silver plan's out-of-pocket max can legally run all the way up to the general ACA ceiling, while an HDHP paired with an HSA is capped lower by IRS rule as a condition of HSA eligibility. When comparing plans, check which limit actually applies to the specific plan you're quoted — don't assume every plan runs to the higher ACA-wide number.
Where you shop also matters mechanically, if not for the cap itself: per CMS, 28 states use HealthCare.gov directly for 2026 enrollment, while 21 states plus D.C. run a fully state-based marketplace with its own enrollment platform (a further 2 states run their own state-based marketplace on the federal platform). The out-of-pocket maximum rule is federal and applies the same either way — but where you actually enroll changes which site quotes you the number.
Sources: HHS — Notice of Benefit and Payment Parameters for 2026 , IRS Rev. Proc. 2025-19 — 2026 HSA/HDHP limits , CMS — Marketplaces by Type, Plan Year 2026
Analysis by the ClearValue Editorial Team, applying our published scoring methodology.
This analysis combines cited public data (Federal Reserve, FDIC, CFPB, SBA, IRS, HHS, or similar primary sources, as cited above) with ClearValue's own math and comparison for this question — it is not proprietary ClearValue applicant data. Figures carry an as-of date; rates, limits, and program terms change, so verify current numbers at the linked primary sources before deciding. Educational information, not financial, legal, or tax advice.
Federal sources
- For plan year 2026, the out-of-pocket maximum for an ACA marketplace plan is $10,150 for self-only coverage and $20,300 for family coverage — up from $9,200 and $18,400 in 2025. Amounts above these limits may not be charged to enrollees. — HHS / HealthCare.gov
- The 2026 out-of-pocket maximum for an HSA-eligible high-deductible health plan is $8,500 for self-only coverage and $17,000 for family coverage — a separate, lower cap than the general ACA marketplace limit. — IRS — Revenue Procedure 2025-19
Key takeaways
- Out-of-pocket maximum = annual cap on what you pay; insurer covers 100% beyond it.
- 2026 ACA limits: $10,150 (self-only), $20,300 (family) — up from $9,200 / $18,400 in 2025.
- HSA-eligible HDHPs have a separate, lower IRS cap for 2026: $8,500 (self-only), $17,000 (family).
- Premiums do NOT count toward this limit.
- Applies to in-network covered services; out-of-network may be different.
- If you have a serious illness or surgery, hitting the out-of-pocket max can save thousands.
Published 2026-06-03 · Updated 2026-08-25 · https://clearvaluelending.com/answers/what-is-out-of-pocket-maximum