Out-of-pocket maximum (OOP max)
The most you'll pay out of pocket in a plan year before the insurer covers 100% of covered services.
The out-of-pocket maximum is a federal cap on your annual cost-sharing. Once you hit this number, the insurer pays 100% for the rest of the plan year. For 2025, the ACA cap is $9,200 for single coverage and $18,400 for family. Plans can set lower OOP max. Deductibles, copays, and coinsurance ALL count toward OOP max. Premiums do NOT count. Out-of-network costs may have a separate, higher OOP max.
Frequently asked questions
What is out-of-pocket maximum (oop max)?
The out-of-pocket maximum is a federal cap on your annual cost-sharing. Once you hit this number, the insurer pays 100% for the rest of the plan year. For 2025, the ACA cap is $9,200 for single coverage and $18,400 for family. Plans can set lower OOP max. Deductibles, copays, and coinsurance ALL count toward OOP max. Premiums do NOT count. Out-of-network costs may have a separate, higher OOP max.
Related terms
- DeductibleThe amount you pay out of pocket each year before your insurance starts paying. Resets every plan ye
- CoinsuranceYour percentage share of a healthcare service cost after you've met your deductible — usually 10-30%
- CopayA fixed dollar amount you pay for a specific healthcare service (e.g., $30 for an office visit).
- Essential Health Benefits (EHB)The 10 categories of services all ACA-compliant plans must cover. No annual or lifetime dollar limit
Sources
Contact: hello@denialhelp.com