Out-of-Pocket Maximum

The most you’ll pay in a plan year for covered care. Hit it, and the plan pays 100% of covered costs after that. The financial airbag.

The out-of-pocket maximum is the most you’ll pay for covered health care in a plan year. Once you hit it, your plan pays 100% of covered services for the rest of the year.

It’s the financial airbag of a health plan: deductibles, copays, and coinsurance all count toward it (premiums don’t), so no matter how bad a year gets medically, your spending on covered care is capped. For a serious illness or surgery, that cap is what stands between you and open-ended bills.

When comparing plans, the out-of-pocket maximum matters as much as the premium — a cheaper plan with a high max can cost far more in a bad year.

This is a friendly general explanation, not legal or policy language. Exact coverage depends on your policy, carrier, and state. 🤝

Written and reviewed by the We Insure Things team — licensed independent insurance agents. Last reviewed July 23, 2026. Questions? Ask a licensed agent.