Out-of-Pocket Maximum
The most you will pay for covered health care services in a policy year before the insurer pays 100% of further costs.
The out-of-pocket maximum (OOPM) is the annual cap on your share of covered health care costs. Once your total payments—including deductibles, copays, and coinsurance—reach the OOPM for the year, the insurer covers 100% of covered in-network services for the remainder of the year. This protects against catastrophic health care costs.
For 2024, ACA-compliant plans cap individual OOPM at $9,450 and family OOPM at $18,900. Premium payments do not count toward the OOPM, nor do out-of-network costs on plans with networks, or costs for non-covered services. Premium amounts do not count toward the OOPM.
Choosing a plan involves trading off lower premiums (which favor high-OOPM/high-deductible plans) against lower financial risk in a bad health year (which favors low-OOPM plans). If you have a chronic condition or anticipate significant medical costs, a lower-OOPM plan may offer better total value even with a higher premium.
Real-World Example
After a hospitalization and surgery, the patient hit her $7,500 out-of-pocket maximum in April; the insurer covered 100% of all further covered costs through December.