The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
The out-of-pocket limit doesn't include:
- Your monthly
The amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance. If you have a Marketplace health plan, you may be able to lower your costs with a premium tax credit.
Refer to glossary for more details.
- Anything you spend for services your plan doesn't cover
- Out-of-network care and services
- Costs above the allowed amount for a service that a provider may charge
The out-of-pocket limit for Marketplace plans varies, but can’t go over a set amount each year.
- For the 2024 plan year:The out-of-pocket limit for a Marketplace plan can’t be more than$9,450 for an individual and$18,900for a family.
- For the 2023 plan year:The out-of-pocket limit for a Marketplace plan can’t be more than$9,100for an individual and$18,200for a family.
Related content
- How to estimate your total costs for health care
- Marketplace insurance plan categories
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
Refer to glossary for more details.
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
Refer to glossary for more details.
A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
Refer to glossary for more details.
