Out-of-Pocket Maximum: 2026 Federal Limits and What Counts

Your out-of-pocket maximum is the most you can be required to pay in a plan year for covered, in-network healthcare. For 2026, federal law caps that figure at $10,600 for individual coverage and $21,200 for family coverage under standard ACA plans. Once your spending hits the limit, your insurer pays 100% of your covered in-network care for the rest of the plan year. The cap counts deductibles, copays, and coinsurance. It does not count premiums or out-of-network charges.¹

How the Cap Works

Treat the limit as a running tally. Every covered dollar you pay out of pocket for in-network care gets added to your accumulator. When the total reaches your plan’s cap, your cost-sharing stops for the remainder of the plan year.¹

Most plan years run January through December. Some employer plans use a different start date. Either way, when a new plan year begins, your accumulator resets to zero and you start building toward the cap again.

The federal government sets the ceiling each year, and insurers can go lower but not higher.²

2026 Federal Limits

Two different federal maximums apply, depending on your plan type.

Standard ACA Plans

For 2026, no individual or small-group plan can require more than $10,600 in cost-sharing for a single person or $21,200 for a family.³ Many plans set lower caps.

HSA-Qualified High-Deductible Plans

If your plan is paired with a Health Savings Account, the IRS imposes tighter limits. For 2026, an HSA-eligible high-deductible plan cannot have an out-of-pocket maximum above $8,500 for self-only coverage or $17,000 for family coverage.⁴

What Counts Toward Your Cap

Three kinds of spending add up:¹

Your deductible, the flat amount you pay before insurance starts sharing costs.
Copays, the fixed dollar amounts you owe per visit or service.
Coinsurance, the percentage share you owe on a bill after meeting the deductible.

These payments count only when they apply to essential health benefits delivered by in-network providers.⁵ Your insurer tracks the running total through its claims system. Keeping your own records is still smart as you get close to the limit.

What Doesn’t Count

Federal law excludes three categories from the calculation:²

Premiums. Your monthly payment to keep the policy active never counts, no matter how high.
Balance billing from out-of-network providers. When an out-of-network provider charges above your insurer’s allowed amount, the difference comes out of your pocket but doesn’t move you closer to the cap.
Non-covered services. Anything your plan doesn’t cover, such as elective cosmetic work, falls entirely outside the limit.

The No Surprises Act narrows the balance-billing exposure. For most emergency care, for out-of-network providers who treat you at an in-network facility, and for out-of-network air ambulance services, your insurer must treat your cost-sharing as in-network, and those payments count toward your in-network cap.⁶ Outside those scenarios, out-of-network costs still won’t accumulate.

The Embedded Individual Limit on Family Plans

Family coverage carries a second layer of protection many enrollees miss. When a family plan’s cap sits above the federal individual limit, the plan must include an embedded individual cap. For 2026, that means no single person on a family plan can be required to pay more than $10,600, even if the household is nowhere near the $21,200 aggregate.³

Say one family member has major surgery in February and runs up $10,600 in cost-sharing. From that point, the insurer covers 100% of that person’s in-network care for the rest of the year. The other family members keep paying their normal share until household spending reaches the full family cap.

After You Hit the Cap

Your insurer pays the full allowed amount for every covered, in-network service for the rest of the plan year.¹ No more pharmacy copays, no coinsurance on imaging, no out-of-pocket charges on bloodwork. The protection runs until the plan year resets.

Two caveats. The coverage applies only to in-network, covered care. If you choose to see an out-of-network specialist after reaching your cap, you’re likely on the hook for the full bill. And you still owe your monthly premium. Stop paying it and your coverage can be canceled regardless of where your accumulator stands.

Lower Caps for Lower Incomes

If you buy a silver plan through the Health Insurance Marketplace and your household income is below 250% of the federal poverty level, a cost-sharing reduction can lower your out-of-pocket maximum substantially. For 2026 the reduced limits fall into two tiers:

Income between 100% and 200% of the federal poverty level: the individual cap drops to roughly $3,500 and the family cap to about $7,000.
Income between 200% and 250% of the federal poverty level: the individual cap drops to around $8,450 and the family cap to about $16,900.

Cost-sharing reductions attach only to silver-tier Marketplace plans. There’s no separate application; the subsidy builds into the plan at enrollment once your income is verified. If your income sits near these thresholds, picking a silver plan over bronze or gold can save thousands in a heavy medical year.

Copay Accumulator Programs

If you use a manufacturer copay card to help pay for an expensive brand-name drug, watch for a practice that can quietly undo your progress. Many insurers now run copay accumulator programs. They accept the manufacturer’s payment at the pharmacy but refuse to credit it toward your deductible or out-of-pocket maximum. When the copay card is exhausted, you owe the full cost-sharing amount, and none of the earlier payments moved your accumulator.

The legality of these programs has been contested. A federal district court ruled in 2023 that the ACA’s definition of cost-sharing covers “any expenditure required by or on behalf of an enrollee,” meaning manufacturer assistance should count. The federal government declined to enforce that ruling and has not issued a replacement regulation. Many insurers continue running accumulator programs, especially for drugs with no generic equivalent. If you rely on copay assistance, read your plan documents for the terms “copay accumulator” or “copay adjustment program” before assuming those payments count.

Plans That Don’t Follow These Rules

Not every plan is bound by the ACA cap.

Original Medicare

Parts A and B have no annual out-of-pocket cap. Cost-sharing can keep climbing with no ceiling.⁷ Medicare Advantage plans (Part C) are required to include an annual cap; the 2026 Medicare Advantage cap is $9,250, and plans can set it lower. Separately, the Inflation Reduction Act capped Medicare Part D prescription drug costs at $2,000 per year starting in 2025, with annual indexing.

Short-Term Health Plans

Short-term, limited-duration policies aren’t regulated by the ACA. They don’t have to cover essential health benefits and aren’t required to cap your spending. Read the policy before you rely on one.

Grandfathered Plans

Plans that predate the ACA and haven’t materially changed benefits or cost-sharing can keep grandfathered status and sit outside some ACA rules. If you’re on one through an employer, your out-of-pocket rules may differ.

Changing Plans Mid-Year

What happens to your accumulator depends on how you change coverage.

COBRA Continuation

Electing COBRA continues the same group health plan. Your deductible and out-of-pocket progress carry over because COBRA coverage must be identical to what similarly situated active employees receive.⁸ You’ll pay the full premium plus up to a 2% administrative fee, so the monthly cost rises sharply.

Starting at a New Employer

Enroll in a new employer’s plan and your spending resets to zero. The new plan has no obligation to credit anything you paid under the old one. Someone who met $7,000 of a $9,000 deductible in June starts fresh at $0 in July. If you have a planned surgery or ongoing treatment, the timing of a job change matters.

Disputing a Miscounted Total

Insurers process huge volumes of claims and sometimes get the math wrong. A covered expense might not be credited, or a claim might be coded in a way that treats it as non-covered. You have federal rights to push back.

Start with an internal appeal. Your insurer must fully review its decision, and if your situation is urgent, it must expedite.⁹ Keep every explanation of benefits (EOB) statement and compare the amounts against your own records.

If the internal appeal fails, you have the right to an external review by an independent third party. You must file for external review within four months of the denial. The reviewer must issue a decision within 45 days under the standard process, or 72 hours for urgent cases, and the insurer is legally required to accept the result. Federal external review, administered by HHS, is free. State-administered external review cannot cost you more than $25.¹⁰

The process is worth pursuing when the dollar amounts are meaningful. A single hospital stay that fails to credit toward your cap can be the difference between hitting the ceiling in September and paying full cost-sharing through December.

1
HealthCare.gov. Out-of-Pocket Maximum/Limit
2
Office of the Law Revision Counsel. 42 USC 18022 – Essential Health Benefits Requirements
3
Federal Register. Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2026
4
Internal Revenue Service. Revenue Procedure 2025-19
5
Centers for Medicare & Medicaid Services. Information on Essential Health Benefits Benchmark Plans
6
U.S. Department of Labor. Avoid Surprise Healthcare Expenses
7
Medicare.gov. Costs
8
U.S. Department of Labor. FAQs on COBRA Continuation Health Coverage for Workers
9
HealthCare.gov. Appeal an Insurance Company Decision
10
HealthCare.gov. External Review