Health
What Is an Out-of-Pocket Maximum?
An out-of-pocket maximum is a cap on what you typically pay for covered, in-network services in a plan year. Premiums usually do not count toward it.
By InsureGuide Editorial Team. Published May 28, 2026. Updated August 8, 2026.
The out-of-pocket maximum (also called an out-of-pocket limit) is the most you would generally pay for covered in-network services during the plan year. After you reach it, the plan typically pays 100% of covered in-network allowed amounts for the rest of that year.
What usually counts
Deductibles, copays and coinsurance for covered in-network care often count toward the maximum. Confirm the list in the plan documents; some plans use a different out-of-network maximum or none at all.
What usually does not count
Monthly premiums almost never count. Non-covered services, amounts over the allowed charge, and some out-of-network costs may not count. Spending after the plan year resets does not carry over.
Why the cap still is not a total budget
Your full yearly cost can still include premiums plus the out-of-pocket maximum, plus anything the plan does not cover. That is why the health calculator shows both an estimated total based on expected spending and a maximum potential annual cost using premium plus the entered out-of-pocket maximum.