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:
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 $18,900 for a family.
For the 2023 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $9,100 for an individual and $18,200 for a family.