Out-of-Pocket Maximum
The annual cap on deductibles, copays, and coinsurance for in network covered care under US health plans.
Overview
After the cap is reached the insurer pays 100 percent of covered in network claims for the rest of the plan year. The ACA sets ceilings indexed yearly, around 9,450 dollars for self only coverage in 2024, and keeps out of network and non covered services outside the cap. Premiums do not count toward the maximum. The design converts catastrophic medical risk into a known annual number, which is the core function of insurance, and makes metal tier comparisons a bet on expected utilization. The cap resets each January, which matters for scheduling expensive procedures near year end.
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