What is an out-of-pocket maximum on a private health plan?
The out-of-pocket maximum is the most you have to pay in a plan year for covered in-network essential health benefits, and once you hit it the plan pays 100% of allowed charges for the rest of the year; for 2026 the federal cap is $10,600 self-only and $21,200 family (CMS Notice of Benefit and Payment Parameters, 2026).
Reviewed by Jason Burns, Editor & Steward · Last verified 2026-07-19
What it means
- Premiums do not count toward the out-of-pocket maximum.
- Non-essential health benefits and out-of-network care may not count toward the cap.
Action steps
- Track cost-sharing through the insurer's member portal each plan year.
- Schedule known procedures late in the year if the cap has already been met.
Risks & deadlines
- A separate, higher out-of-pocket maximum usually applies to out-of-network care.
Sources
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