Health
What Is an Out-of-Pocket Maximum?
An out-of-pocket maximum caps what you typically pay for covered, in-network services in a plan year. Premiums usually do not count toward it.
By Averainsure Editorial Team. Published May 28, 2026. Updated August 8, 2026.
The out-of-pocket maximum (also called an out-of-pocket limit) is generally the most you would 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 toward the cap
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 is still not your full 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.