Out-of-pocket (OOP) maximum is the most you pay for covered services in a plan year.

Once reached, insurance pays 100% of covered costs for rest of year. 2025 ACA limits: $9,450 individual / $18,900 family.

Example: $3,000 deductible, reach $9,450 OOP max after major surgery.

Remaining 3 months of year = $0 patient cost for all covered care.

Protection especially valuable for chronic conditions, cancer treatment, major surgeries.

Counts toward OOP max: Deductibles, copays for covered services, coinsurance (your % after deductible).

Does NOT count: Monthly premiums (biggest expense but separate), out-of-network care in most plans, non-covered services (cosmetic, experimental), charges above plan allowed amounts.

Example: $600/month premiums ($7,200/year) do not reduce your $9,450 OOP maximum.

Total annual costs = premiums + OOP max = up to $16,650.

Family plans have two OOP limits: Individual member limit (embedded): Varies by plan, $5,000-9,450 typical.

Family aggregate limit: $18,900 maximum (2025 ACA).

Once one member hits individual limit, insurance covers that person 100% (others still pay until their limit).

Once family hits aggregate $18,900, insurance covers everyone 100%.

Example: 4-person family, one member has $15,000 surgery.

That member hits individual OOP, covered 100% rest of year.

Others still have cost-sharing until family aggregate hit.

Lower OOP max = higher premiums, better for high healthcare usage.

Higher OOP max = lower premiums, better if healthy.

Example comparison: Silver plan: $500/month premium, $6,000 OOP max, annual max cost $12,000.

Bronze plan: $350/month premium, $9,000 OOP max, annual max cost $13,200.

If you hit OOP max: Silver cheaper ($12k vs $13.2k).

If you use <$2,000 care: Bronze cheaper ($4,200 + $2k = $6.2k vs Silver $6k + $2k = $8k).

Choose based on expected usage and risk tolerance.

OOP max resets with new plan - no credit for previous accumulation.

Example: Leave Job A in June having paid $4,000 toward $8,000 OOP max.

Start Job B with new insurance - OOP counter starts at $0 with new $9,450 maximum.

Could pay up to $4,000 + $9,450 = $13,450 total in one calendar year across two plans.

Strategies: Time elective procedures, COBRA continuation (expensive but maintains accumulation), negotiate start date to begin of year.

Depends on plan type: HMO/EPO: Out-of-network care generally NOT covered, does not count toward OOP max (emergency exceptions).

PPO: Out-of-network has separate higher OOP max, typically 2x in-network limit.

Example: $9,000 in-network OOP max, $18,000 out-of-network.

HDHP: Some plans combine in/out-of-network OOP max.

Always verify with plan documents.

Avoid out-of-network except emergencies - surprise bills can exceed OOP max protection.