Out-of-Pocket Maximum

Bronze: $10,600 max — but with a ~$8,000 deductible and 40% coinsurance, you may hit the cap with one major event
Silver with CSR: As low as $3,000 max for lower-income enrollees
Gold: ~$8,000-$9,000 max in practice
Platinum: ~$4,000-$5,000 max in practice

What Is the Out-of-Pocket Maximum?

The out-of-pocket maximum (also called out-of-pocket limit) is the absolute most you'll pay for covered healthcare services in one year. Once you hit this limit, your insurance pays 100% of covered services for the rest of the plan year. For 2026, the federal limit is $10,600 for an individual and $21,200 for a family.

What Counts Toward Your Out-of-Pocket Maximum

What Does NOT Count

Monthly premiums
Out-of-network charges (on most plans)
Services your plan doesn't cover
Balance-billed amounts above allowed charges

Why This Is the Most Important Number in Health Insurance

The out-of-pocket maximum is your financial safety net. Without insurance, a cancer diagnosis can cost $150,000+. A heart attack: $100,000+. A complicated childbirth: $50,000+. With any ACA-compliant plan — whether purchased on the marketplace or directly from a private carrier — the most you'd ever pay is $10,600 in a year. After that, insurance covers everything.

Family plan protection: On family plans, no single family member can be charged more than the $10,600 individual limit — even if the family hasn't reached the $21,200 family maximum. This prevents one person's medical crisis from consuming the entire family's out-of-pocket cap.