The most you have to pay for covered services in a plan year. After you spend this amount on costs should as deductibles, co-payments, and co-insurance, your health plan will pay 100% of the costs of covered benefits.
The out-of-pocket limit doesn't include your monthly premiums. It also doesn't include anything you spend for services your plan doesn't cover.
Example of out-of-pocket maximum with high medical costs:
Total surgery costs: 20,000
Your deductible: $1,300
Your co-insurance: $3,740 (Your 20% coinsurance on the rest of the costs ($18,700))
Your total costs: $5,040
Out-of-pocket maximum: $4,400 (Your insurance company pays all covered costs above $4,400 and any covered care for the rest of the year.)
Generally, plans with lower monthly premiums have higher out-of-pocket limits. Plans with higher premiums usually have lower out-of-pocket maximums.
For the 2025 plan year: The out-of-pocket limit for a Marketplace plan can't be more than $9,200 for an individual and $18,400 for a family.