Out-of-Pocket Maximum (OOPM)
Definition current for the 2026 plan year · Last reviewed July 2026
In one sentence: The annual ceiling on what you pay for covered, in-network care — at most $10,600 per person in 2026.
The out-of-pocket maximum is the number that makes insurance insurance: once your deductibles, copays, and coinsurance for covered in-network care hit this ceiling, the plan pays 100% for the rest of the year. For 2026 the federal limit is $10,600 for an individual / $21,200 for a family; many plans set lower ones, and CSR-boosted silver plans can cut it to $3,000 or less.
What does not count toward it: premiums, out-of-network care (often unlimited exposure), and anything the plan doesn't cover. That out-of-network exclusion is why network type (HMO vs PPO) matters more than most shoppers think.
Use the OOPM as your stress test: when comparing plans, add each plan's annual premium to its OOPM. That sum is your true worst-case year — and it sometimes ranks plans very differently than premiums alone. This is the heart of the bronze-vs-silver break-even math in our guide.