Updated November 2026 with 2027 limits. Your deductible is what you pay for covered care before the plan starts sharing costs. Your out-of-pocket maximum is the most you can pay for covered, in-network care in a year; after you hit it, the plan pays 100%. Every ACA-compliant plan has both, and the gap between them is where most of a bad year’s medical bills land.
Deductible vs Out-of-Pocket Maximum at a Glance
| Deductible | Out-of-Pocket Maximum | |
|---|---|---|
| What it is | The amount you pay before the plan starts paying for most services | The cap on what you pay for covered in-network care in a plan year |
| What counts toward it | Payments for services subject to the deductible | Deductible, copays and coinsurance for covered in-network care |
| What does not count | Premiums, most copays, preventive care (free) | Premiums, out-of-network care in most plans, non-covered services, balance bills |
| After you reach it | You pay copays or coinsurance | The plan pays 100% of covered in-network care |
| Federal limit for 2027 | None for most plans | $12,000 self-only, $24,000 family |
How the Two Work Together: An Example
Take a plan with a $3,000 deductible, 20% coinsurance and a $9,000 out-of-pocket maximum. You need surgery that the plan prices at $60,000.
- You pay the first $3,000, your deductible.
- You then pay 20% of the remaining $57,000, which would be $11,400.
- Your total is capped at $9,000, so you stop at $6,000 of coinsurance.
- For the rest of the plan year, covered in-network care costs you nothing.
Coinsurance is your percentage share of a bill after the deductible; a copay is a flat fee, such as $40 for an office visit. Both count toward the out-of-pocket maximum.
Out-of-Pocket Limits for 2026 and 2027
| Limit | 2026 | 2027 |
|---|---|---|
| ACA maximum out-of-pocket, self-only | $10,600 | $12,000 |
| ACA maximum out-of-pocket, family | $21,200 | $24,000 |
| HSA-qualified high-deductible plan, minimum deductible (self/family) | $1,700 / $3,400 | $1,750 / $3,500 |
| HSA-qualified high-deductible plan, maximum out-of-pocket (self/family) | $8,500 / $17,000 | $8,700 / $17,400 |
The ACA limits come from the Centers for Medicare & Medicaid Services (CMS) 2027 premium adjustment guidance; the high-deductible plan figures come from IRS Revenue Procedures 2025-19 and 2026-24. The 2027 jump is unusually large, about 13%, because of a change in how federal regulators index the limit.
What Does Not Count Toward Either
- Monthly premiums.
- Care your plan does not cover, such as most cosmetic procedures.
- Out-of-network care in HMO and EPO plans, and in most PPOs, which have a separate and higher out-of-network limit.
- Balance bills from out-of-network providers, outside the situations the No Surprises Act protects.
Family Plans: Embedded vs Aggregate Deductibles
On a family plan, an “embedded” deductible gives each person an individual deductible inside the family one, so one sick child can reach the plan’s sharing without the whole family meeting the larger figure. An “aggregate” deductible must be met in total before the plan pays for anyone. ACA rules also cap any one person’s costs at the self-only out-of-pocket maximum, even on a family plan.
How To Use These Numbers When You Shop
- Add twelve months of premiums to the out-of-pocket maximum to see your worst-case year.
- If you expect surgery, a pregnancy or ongoing treatment, a plan with a lower out-of-pocket maximum often wins, even with a higher premium.
- If you are healthy and have savings, a high-deductible plan paired with a health savings account (HSA) can cost less overall; see our HSA and FSA limits guide.
- Check whether your prescriptions have their own deductible.
- Confirm your doctors are in network, since out-of-network bills may not count toward the cap at all.
Network type changes the math too; our HMO vs PPO vs EPO guide explains why. For plan options, see our high-deductible health plans guide.
Sources
CMS, Premium Adjustment Percentage and Maximum Annual Limitation on Cost Sharing guidance for 2026 and 2027; IRS Revenue Procedures 2025-19 and 2026-24; HealthCare.gov glossary.