Out-of-Pocket Maximum

The most a patient will pay for covered healthcare services in a plan year, after which the insurance plan pays 100% of covered services.

The out-of-pocket maximum is the ceiling on what a patient pays for covered services in a single plan year. Once they hit this limit, the payer covers everything at 100% for the rest of the year. For providers, this matters because it affects patient payment behavior and collections throughout the year. ACA marketplace plans cap out-of-pocket maximums. For 2026, the limit is approximately $9,200 for an individual and $18,400 for a family, though specific plan limits may be lower. Employer-sponsored plans often have lower out-of-pocket maximums as well. The out-of-pocket maximum includes all copays, coinsurance, and deductible payments the patient makes. It generally does not include premiums, out-of-network charges, or services that are not covered by the plan. From a billing perspective, the out-of-pocket maximum creates a predictable pattern in patient payments throughout the year. In January, most patients have not met their deductible, so you collect more from patients directly. By mid-year, many patients have met their deductible and are in the coinsurance phase. By late year, some patients have hit their out-of-pocket max, meaning the payer covers everything. This cycle affects your cash flow. January through March tends to have higher patient collections but more collection effort. October through December tends to have lower patient responsibility because many patients have hit or are close to their out-of-pocket maximum. For credentialing, the out-of-pocket maximum does not directly affect the process. But understanding how it works helps you communicate with patients about their financial responsibility and explains why the same patient might owe $150 for a visit in February but $0 for the same visit in November. Verify the patient's out-of-pocket maximum status during eligibility checks. Most eligibility verification tools show how much of the deductible and out-of-pocket maximum has been met. This information helps your front desk collect the right amount at the time of service.