Out-of-pocket maximum
The out-of-pocket maximum (OOP max) is the most you will pay for covered health care in a plan year. Once you reach this limit, your insurer pays 100% of covered costs for the rest of the year. It includes deductibles, coinsurance, and copays — but typically not premiums. Also called out-of-pocket limit.
How the OOP max protects you
The out-of-pocket maximum is the ceiling on your annual cost-sharing. Once you have paid your deductible, your coinsurance, and any copays up to the OOP max, your insurer covers 100% of covered costs for the remainder of the plan year. In the US, ACA-compliant plans set a maximum annual OOP cap ($9,450 for individual coverage in 2024).
A plan with a lower OOP max provides greater financial protection in a serious illness year, but typically charges a higher premium. See our guide to deductible and out-of-pocket maximum for worked examples.