Deductible vs Out-of-Pocket Maximum: What You Actually Pay

The four numbers

Term	HealthCare.gov definition	Counts toward the out-of-pocket maximum?
Premium	the amount you pay for your health insurance every month	no
Deductible	the amount you pay for covered health care services before your insurance plan starts to pay	yes
Copayment	a fixed amount, $20 for example, you pay for a covered service after you have paid your deductible	yes
Coinsurance	the percentage of the cost of a covered service you pay, 20 percent for example, after you have paid your deductible	yes
Out-of-pocket maximum	the most you have to pay for covered services in a plan year; after it, the plan pays 100 percent of covered in-network benefits	it is the ceiling

The order is the key. In a plan year you pay covered bills in full until the deductible is met; then you pay only a copayment or coinsurance on each service; and once what you have paid in deductible, copayments and coinsurance reaches the out-of-pocket maximum, the plan pays everything covered and in network for the rest of the year. HealthCare.gov adds that many plans pay for certain services, such as a checkup, before the deductible is met.

What does not count

HealthCare.gov lists what the out-of-pocket maximum does not include: your monthly premiums; anything you spend on services the plan does not cover; out-of-network care and services; and charges a provider bills above the plan's allowed amount. A year with high premiums and no care therefore has an out-of-pocket total of zero against the maximum, and a year of out-of-network care can cost far more than the maximum suggests.

The federal limits

HealthCare.gov publishes the out-of-pocket maximums for Marketplace plans by plan year, the most a plan may set. Plans may set lower ones.

Plan year	Individual	Family
2026	$10,600	$21,200
2027	$12,000	$24,000

One plan, a year of bills

Take a plan with a $450 monthly premium, a $3,000 deductible, 20 percent coinsurance and an $8,000 out-of-pocket maximum, all in network. The table shows what you pay for a year whose covered medical costs total the first column, before premiums.

Your share of a year's covered in-network costs

min( deductible paid + coinsurance % × (costs − deductible), out-of-pocket maximum )

Covered costs in the year	Deductible paid	Coinsurance paid	Your total for care	Plus $5,400 of premiums
$500	$500	$0	$500	$5,900
$1,500	$1,500	$0	$1,500	$6,900
$3,000	$3,000	$0	$3,000	$8,400
$6,000	$3,000	$600	$3,600	$9,000
$12,000	$3,000	$1,800	$4,800	$10,200
$25,000	$3,000	$4,400	$7,400	$12,800
$60,000	$3,000	$5,000	$8,000	$13,400

Three regions show up. Below the deductible you pay every dollar. Between the deductible and the maximum you pay 20 cents of each dollar, so the $12,000 year costs $4,800, which is HealthCare.gov's own coinsurance example. From $28,000 of covered costs upward the maximum takes over and the $60,000 year costs the same $8,000 as the $25,000 year. The last column is what the year really costs, and it is the number to compare between plans, not the premium alone.

Comparing two plans

A low-premium plan usually has a high deductible and maximum, a high-premium plan the reverse, and which one is cheaper depends on how much care the year brings. The comparison is the last column of the table above for each plan at a low, a medium and a worst-case year: premiums times twelve, plus the share of care up to that plan's maximum. The worst case is the premium total plus the out-of-pocket maximum, and that sum is the most the plan can cost you for in-network covered care in a year; it is the figure an emergency fund should be able to cover. A high-deductible plan can also come with a health savings account, and the guide HSA vs FSA covers the 2026 limits for paying these costs with pre-tax money; the budget planner holds the premium next to the rest of the month, and the paycheck calculator shows a premium taken from pay before tax.

Reading the plan summary

Individual or family deductible and maximum. Family plans carry both; check whether one person's bills can meet the individual figure inside the family one.
In network only. The maximum protects in-network covered care; out-of-network has separate, higher figures or none.
Services before the deductible. Preventive visits and some generics are often covered first; the plan summary lists them.
Copay or coinsurance per service. Office visits are often a copay, hospital care coinsurance; both count toward the maximum.
Plan year, not calendar year. Deductible and maximum reset at the start of the plan year, which for employer plans may not be January.

This guide uses the federal Marketplace definitions and limits. Employer plans, Medicare and Medicaid use related terms with their own figures, and the plan's summary of benefits and coverage is the document that governs.

Frequently asked questions

What is the difference between a deductible and an out-of-pocket maximum?

The deductible is the amount you pay for covered services before the plan starts to pay; the out-of-pocket maximum is the most you pay for covered in-network services in a plan year, after which the plan pays 100 percent. The deductible comes first and counts toward the maximum, so do copayments and coinsurance. Premiums count toward neither.

What is the out-of-pocket maximum for 2026?

For Marketplace plans the HealthCare.gov glossary gives $10,600 for an individual and $21,200 for a family for the 2026 plan year, rising to $12,000 and $24,000 for 2027. These are the most a Marketplace plan may set; a plan can set a lower maximum.

Do premiums count toward the deductible?

No. The premium is the amount you pay for your health insurance every month whether you use care or not, and HealthCare.gov lists it among the costs that do not count toward the out-of-pocket maximum. The deductible and the maximum only track what you pay for covered services.

What is coinsurance?

The percentage of the cost of a covered service you pay after you have met the deductible, 20 percent for example. HealthCare.gov's illustration: with a $3,000 deductible and 20 percent coinsurance, $12,000 of treatment costs you the $3,000 deductible plus 20 percent of the remaining $9,000, $1,800, a total of $4,800, unless the out-of-pocket maximum is lower.

Is a copay the same as coinsurance?

No. A copayment is a fixed dollar amount for a service, $20 for an office visit for example, usually after the deductible; coinsurance is a percentage of the allowed cost. HealthCare.gov's example: a $100 office visit costs $100 before the deductible is met and the $20 copay after. Both count toward the out-of-pocket maximum.

Sources

Written by Tobias Kurth, designer. Updated October 20, 2026.