How Health Insurance Deductibles Work: Copays, Coinsurance
See how deductibles, copays, coinsurance, and out-of-pocket maximums divide your health care costs.
What Is an Out-of-Pocket Maximum? 2026 Limits
Key takeaway
See how covered, in-network cost sharing works with an out-of-pocket maximum in a Marketplace plan.
An out-of-pocket maximum is a limit on certain health-plan cost sharing, not a ceiling on every health expense. HealthCare.gov defines it as “the most you have to pay for covered services in a plan year.” Its Marketplace guidance ties that limit to covered, in-network care and services. (HealthCare.gov: Out-of-pocket maximum/limit)
TL;DR: For the 2026 plan year, a Marketplace plan’s out-of-pocket limit cannot be more than $10,600 for an individual or $21,200 for a family. After you spend the limit on deductibles, copayments, and coinsurance for in-network care and services, the plan pays 100% of the costs of covered benefits. (HealthCare.gov: Out-of-pocket maximum/limit)
What Is an Out-of-Pocket Maximum?
HealthCare.gov describes the maximum as the most you will spend for covered services in a year. After you reach the amount, the insurer pays 100% for covered services. That description is plan-specific: the services still must be covered, and the network and other policy terms matter. (HealthCare.gov: Your total health care costs)
For Marketplace plans in 2026, HealthCare.gov states that the limit cannot exceed:
- $10,600 for an individual
- $21,200 for a family
Those are Marketplace-plan maximum limits for the stated plan year, not a statement that every plan uses the same limit. (HealthCare.gov: Out-of-pocket maximum/limit)
What Counts Toward the Limit?
HealthCare.gov says that, after you spend the amount on deductibles, copayments, and coinsurance for in-network care and services, the plan pays 100% of the costs of covered benefits. The same page identifies important exclusions from the limit. (HealthCare.gov: Out-of-pocket maximum/limit)
| Cost or service | HealthCare.gov’s Marketplace guidance |
|---|---|
| Deductibles for in-network care and services | Counts toward the limit |
| Copayments for in-network care and services | Counts toward the limit |
| Coinsurance for in-network care and services | Counts toward the limit |
| Monthly premium | Does not count toward the limit |
| Services the plan does not cover | Do not count toward the limit |
| Out-of-network care and services | Do not count toward the limit |
| Costs above the allowed amount that a provider may charge | Do not count toward the limit |
The table does not mean the limit pays for those excluded costs. It separates covered, in-network cost sharing from costs outside the Marketplace out-of-pocket limit.
How Does It Work With a Deductible and Coinsurance?
The deductible and coinsurance are forms of cost sharing that can accumulate toward the limit when the care and services are in network and covered. A simple hypothetical makes the arithmetic easier to see:
- A family has a plan with a $4,000 deductible and 20% coinsurance.
- The family receives covered, in-network care and first pays the $4,000 deductible.
- Coinsurance then adds to the family’s cost sharing until the family reaches the out-of-pocket limit in its plan.
- After the applicable limit is reached, the plan pays 100% of the costs of covered benefits for the rest of that plan year.
The numbers in that example are illustrative. Your plan’s deductible, coinsurance, network rules, and out-of-pocket limit determine what happens in an actual claim or course of care.
What Should You Check Before You Enroll?
HealthCare.gov advises comparing a plan’s estimated total yearly costs, not just the premium. When reviewing a Marketplace plan, identify:
- the out-of-pocket limit for the plan year;
- whether the services and providers you expect to use are in network;
- the deductible, copayment, and coinsurance terms; and
- the services the plan covers.
This helps distinguish a premium from the cost sharing that can count toward the plan’s out-of-pocket maximum. (HealthCare.gov: Your total health care costs)
Keep the Scope Narrow
An out-of-pocket maximum is meaningful protection for covered, in-network services, but it is not a promise that every medical expense is capped. Review the plan materials for the network, covered benefits, and exact limit that apply to you. For a related overview, see our guide to how health insurance deductibles work.
This article is for general informational purposes only and does not constitute financial, legal, insurance, or medical advice. Coverage terms, out-of-pocket limits, networks, and plan details vary by carrier, state, and individual circumstances. Review your own plan documents or speak with a licensed insurance agent or navigator before making coverage decisions.
This article is general information, not financial, legal, or insurance advice. Coverage, pricing, and eligibility vary by carrier, state, and individual circumstances. Talk to a licensed agent or review your policy documents before making decisions.
Frequently Asked Questions
What is an out-of-pocket maximum in simple terms?
HealthCare.gov defines it as the most you have to pay for covered services in a plan year. After you spend the amount on deductibles, copayments, and coinsurance for in-network care and services, the plan pays 100% of the costs of covered benefits.
What is the out-of-pocket maximum for 2026?
For the 2026 plan year, a Marketplace plan cannot have an out-of-pocket limit above $10,600 for an individual or $21,200 for a family. The applicable limit and plan terms should be checked in your own plan materials.
Does the out-of-pocket maximum include my deductible?
For in-network care and services, HealthCare.gov says deductibles, copayments, and coinsurance count toward the out-of-pocket limit. Check your own plan materials for its terms.
Does my monthly premium count toward the out-of-pocket maximum?
No. HealthCare.gov says the out-of-pocket limit does not include the monthly premium.
Do employer health plans have lower out-of-pocket maximums than Marketplace plans?
This article does not make a general employer-plan comparison. Check the out-of-pocket limit, network, and covered-benefit terms in the materials for the plan you are considering.
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