Is the out-of-pocket maximum per person or per family?

Family plans have both. Each covered person has an individual cap, and the family cap applies to the household total.

Does the deductible count toward the out-of-pocket maximum?

Yes. The deductible, copays and coinsurance for covered in-network care all count.

Do prescription costs count?

Covered drugs bought at an in-network pharmacy count. Drugs not on the plan formulary generally do not.

What the out-of-pocket maximum protects you from

The ceiling on what you pay for covered in-network care in a plan year. After you hit it, the plan pays 100 percent of covered services.

The number that defines your worst year

The out-of-pocket maximum is the most you can pay for covered in-network services in a plan year. Once your deductible, copays and coinsurance add up to that figure, the plan pays the full cost of covered care for the rest of the year.

This is the number to read first when you compare plans. The premium tells you the cost of a healthy year. The out-of-pocket maximum tells you the cost of a bad one.

What does not count toward it

The cap is narrower than people expect, and every exclusion is a real bill.

Monthly premiums never count
Care from an out-of-network provider, on most plans
Services the plan does not cover at all, such as most adult dental and vision
Charges above the plan's allowed amount when you go out of network

Why network checks decide this

Because out-of-network care usually sits outside the cap, the network is the protection, not the number. Confirm your hospital, your specialist and the anesthesia and lab groups they use are in network before you enroll.

Check your providers against each plan you are considering, not just the plan you expect to pick.

Federal limits

Every Marketplace plan must set its out-of-pocket maximum at or below the federal limit for that plan year, and silver plans with cost sharing reductions sit well below it. The exact limits are published by CMS each year and are reflected in the plan detail we show for your county.

Common questions

Is the out-of-pocket maximum per person or per family?: Family plans have both. Each covered person has an individual cap, and the family cap applies to the household total.
Does the deductible count toward the out-of-pocket maximum?: Yes. The deductible, copays and coinsurance for covered in-network care all count.
Do prescription costs count?: Covered drugs bought at an in-network pharmacy count. Drugs not on the plan formulary generally do not.