The ACA out-of-pocket maximum is the annual ceiling on what a plan member pays for covered essential health benefits from in-network providers. Once the OOPM is reached, the insurer pays 100 percent of additional covered in-network costs for the rest of the plan year. It is distinct from the deductible, which is only the amount paid before cost-sharing begins.
Key Takeaways
- The ACA out-of-pocket maximum is the annual ceiling on what a member pays for covered essential health benefits from in-network providers. Once reached, the plan pays 100 percent of those costs for the rest of the plan year.
- For plan year 2026, CMS set the OOPM ceiling at $9,450 for self-only coverage and $18,900 for family coverage in the NBPP. Individual plans may set lower limits, but cannot exceed the CMS ceiling.
- Premiums, out-of-network costs (with limited exceptions under the No Surprises Act), and services that are not essential health benefits do not count toward the OOPM.
- Silver plans with cost-sharing reductions carry significantly lower OOPMs. The 94% actuarial value CSR tier can reduce the individual OOPM to approximately one-fifth of the standard ceiling, depending on the plan and plan year.
- Since plan year 2016, ACA plans must embed an individual OOPM within family coverage. No individual family member can be required to pay more than the individual OOPM amount, even if the family aggregate has not been reached.
What the OOPM covers and what it does not
The OOPM accumulates from deductibles, copays, and coinsurance paid for covered essential health benefits received from in-network providers. It does not accumulate from premiums. A client who pays $350 per month in premiums and $5,000 in covered medical cost-sharing has $5,000 of OOPM accumulation, not $9,200.
Out-of-network costs generally do not count toward the in-network OOPM unless the applies. Under the No Surprises Act, cost-sharing for emergency care and certain out-of-network services at in-network facilities is calculated at in-network rates and does count toward the OOPM. Outside those protected categories, any amount a client pays to out-of-network providers counts only toward a separate out-of-network OOPM if the plan has one, and many plans do not.
Services that are not essential health benefits are not subject to the OOPM at all. Cosmetic procedures, adult dental (unless the plan adds it), and services excluded from the plan design are charged at the full billed rate with no OOPM protection.
2026 OOPM limits by plan type
For plan year 2026, CMS set the maximum OOPM at $9,450 for self-only coverage and $18,900 for family coverage in the Notice of Benefit and Payment Parameters. Carriers may set lower OOPMs on individual plans but cannot exceed the CMS ceiling. Plans that exceed the ceiling are not ACA-compliant. Silver CSR plans are a notable exception: their OOPMs are dramatically reduced as part of the cost-sharing reduction benefit.
| Plan tier | Actuarial value | Typical OOPM range | Notes |
|---|---|---|---|
| Bronze | ~60% | Up to $9,450 (self-only) | High deductible, high OOPM. Many Bronze plans are HDHPs eligible for HSA pairing. |
| Silver (standard) | ~70% | Up to $9,450 (self-only) | Same OOPM ceiling as Bronze. CSR tier assignment changes everything for eligible clients. |
| Silver 73% CSR | ~73% | Lower than standard; varies by plan | Applies to households at 200 to 250 percent FPL. Modest reduction to OOPM and cost-sharing. |
| Silver 87% CSR | ~87% | Substantially lower; varies by plan | Applies to households at 150 to 200 percent FPL. Deductible and OOPM both drop significantly. |
| Silver 94% CSR | ~94% | Dramatically lower; can be under $1,750 (self-only) | Applies to households at 100 to 150 percent FPL. Often provides better value than Gold. |
| Gold | ~80% | Lower than Bronze; often $2,000–$4,000 (self-only) | No CSR. Typically lower deductible and OOPM than Silver standard, but premium is higher. |
| Platinum | ~90% | Lowest standard tier; often under $2,000 (self-only) | Highest premium. Best value for clients with predictably high healthcare utilization. |
OOPM ranges are illustrative. Actual limits depend on the specific plan, rating area, plan year, and CMS cost-sharing reduction parameters in the NBPP.
How Silver CSR plans change the OOPM
Cost-sharing reduction on Silver plans does not just reduce the deductible. It reduces the entire cost-sharing structure: deductibles, copays, coinsurance, and the OOPM. The reduction is significant enough that a Silver 94% CSR plan often provides better financial protection than a Gold plan, despite carrying a Silver-tier premium.
A client at 130 percent FPL who qualifies for the 94% CSR tier on a Silver plan is not on a Silver plan in any practical sense. They are on a plan that functions closer to Platinum in cost-sharing structure while receiving APTC calibrated to Silver. The OOPM on that plan may be under $1,750 for self-only coverage. Compare that to a Gold plan OOPM that typically runs between $2,000 and $4,000 depending on the carrier and rating area. The Silver 94% CSR plan protects the client more at a lower or comparable net premium.
This is the single most underused decision point in ACA plan selection for low-income clients. Many quoting tools, including integrated platforms like Inshura, surface plans by premium. Brokers who sort by net premium without checking the OOPM for CSR-eligible clients will frequently miss the Silver 94% advantage. For the full CSR tier breakdown and FPL income bands, see ACA Silver plan CSR tiers explained.
The embedded individual OOPM rule
Before 2016, some family health plans used an aggregate-only OOPM. Under aggregate design, no individual family member's cost-sharing would trigger plan coverage until the family had collectively spent the full family OOPM amount. In a family with one seriously ill member and three healthy members, the sick member could exhaust their personal resources before the aggregate family OOPM triggered.
CMS eliminated this structure for ACA-compliant family plans in 2016. Every family plan now requires an embedded individual OOPM. Under the embedded design, no individual family member is ever required to pay more than the individual OOPM ceiling in a plan year, even if the family aggregate has not been met.
To illustrate: a family plan has an individual OOPM of $9,450 and a family OOPM of $18,900. One family member has a surgery and accumulates $11,000 in covered cost-sharing. Under the embedded rule, the plan covers any costs beyond $9,450 for that member, and the family aggregate now shows $9,450 of accumulation. The other family members still have $9,450 each before their individual OOPM is met. This is a meaningful financial protection for families with one high-utilization member.
The OOPM reset and mid-year enrollment
The OOPM resets on the plan start date, which for most ACA plans is January 1. A client who enrolls in June under a SEP and pays $4,000 in cost-sharing between July and December has accumulated $4,000 toward that plan year's OOPM. On January 1, that accumulation resets to zero regardless of what they paid in the second half of the prior year.
This matters most for clients approaching the OOPM in the final quarter of the year. A client who has accumulated $8,000 of a $9,450 OOPM in October may want to schedule upcoming elective procedures before December 31, when they would be fully covered by the plan above the $1,450 remaining. January 1, they start over. For the full metal tier interaction and actuarial value comparison, see ACA metal tiers explained.
FAQ
Common questions about the ACA out-of-pocket maximum.
Do premiums count toward the ACA out-of-pocket maximum?
No. Premiums are a separate cost and do not count toward the OOPM under any ACA plan. The OOPM applies only to cost-sharing charges for covered in-network services, including deductibles, copays, and coinsurance. A client who pays $300 per month in premiums and $4,000 in covered medical costs has spent $7,600 total on healthcare, but only the $4,000 in cost-sharing counts toward the OOPM ceiling.
What is the difference between the deductible and the OOPM?
The deductible is the amount a member pays before the plan begins sharing costs. The OOPM is the maximum total a member pays for covered services in a plan year, including the deductible plus any copays and coinsurance paid after the deductible is met. Once the OOPM is reached, the plan covers 100 percent of additional covered costs. A plan with a $3,000 deductible and a $7,500 OOPM requires the member to pay $3,000 before cost-sharing kicks in and cannot charge more than $7,500 total in covered cost-sharing for the year.
If a client switches ACA plans mid-year, does their OOPM spending carry over?
No. Each plan has its own OOPM accumulation. If a client switches plans due to a qualifying life event and enrolls in a new plan under a SEP, their OOPM resets to zero on the new plan's effective date. The prior plan's accumulation is not transferred. This is a meaningful consideration for clients with ongoing high-cost treatments: switching mid-year after meeting most of the deductible on the old plan may mean starting over on the new plan's deductible and OOPM simultaneously.
How does the No Surprises Act affect what counts toward the OOPM?
The No Surprises Act requires that patient cost-sharing for emergency care and certain out-of-network services at in-network facilities be calculated at in-network rates. Because the law caps what the patient is charged at in-network cost-sharing levels for those protected services, those amounts do count toward the in-network OOPM. This means some services delivered by out-of-network providers now count toward the OOPM where they previously would not have. The key qualifier is that the No Surprises Act protections apply to specific service categories — emergency care, air ambulance, and non-emergency services at in-network facilities with out-of-network providers the patient did not voluntarily choose.
Can an ACA plan set an OOPM lower than the CMS ceiling?
Yes. The CMS ceiling is the maximum a plan is allowed to charge. Carriers can and often do set lower OOPMs, particularly on Gold and Platinum plans. The ceiling also sets the embedded individual OOPM limit for family plans. If a carrier sets a family OOPM of $15,000 and the individual embedded limit is $9,450, no single family member will be charged more than $9,450 regardless of total family spending. Plans are also allowed to set separate OOPMs for specific services, though the cumulative total across all cost-sharing must stay within the annual ceiling.
