Out-of-Pocket Maximum Calculator
Your plan and the year you expect
Your result will appear here
Fill in the fields and this updates as you type.
Know what this estimate is based on
- Jurisdiction
- United States — insurance is regulated state by state, so the rules behind a premium are your state's, not a federal schedule
- Rules and time period
- Premiums, limits and deductibles are the figures you enter. Health plan cost-sharing caps, Medicare amounts and state filings all reset annually.
- Scope and limitations
- Educational estimate only. Rates, required coverages and available discounts differ by where you live. Your premium is set by an insurer's own underwriting — driving record, claims history, credit-based insurance score where permitted, the property itself — and only a quote is binding. What a policy pays depends on its exclusions and limits, not on this estimate.
- Source links checked
- Sep 19, 2026
Built and regression-tested by Smart Tools Lab. It has not been individually reviewed by a licensed financial, tax, or legal professional.
How to use
- 01
Enter your monthly premium. It is not part of the out-of-pocket maximum — no plan counts premiums toward the cap — but it is part of what the year costs you, so the page carries it separately and adds it back at the end. Keeping the two apart is the only way to see both what the plan can charge you and what the year actually costs.
- 02
Enter the deductible, your coinsurance share and the out-of-pocket maximum, all three from your summary of benefits and coverage rather than from memory. These are the three terms that describe the whole shape of your cost sharing, and the out-of-pocket maximum is the one that decides your worst case.
- 03
Enter the covered medical bills you expect, as the total providers would bill rather than your share of it. The page then works out where that lands in the three stages: paying everything, paying a percentage, or paying nothing further because the cap has taken over.
- 04
Read the point at which the cap takes over. That figure is usually far larger than people expect — it is the level of billed care, not the level of your own spending, at which your share stops growing — and it is the honest measure of how far away the ceiling really is.
- 05
Read the worst case last, and treat it as the number to plan around. It is the most an in-network year can cost you: your premiums plus the full maximum. Whether you could absorb that figure, from savings or an HSA, is the real question this page exists to answer.
Formula
Your share of the bills follows three stages. Below the deductible you pay everything. Above it you pay the deductible plus your coinsurance percentage of the excess. And the whole amount is capped at the out-of-pocket maximum, so your share = min(out-of-pocket maximum, deductible + (bills − deductible) × coinsurance) once the bills exceed the deductible, and simply the bills when they do not. The plan pays whatever is left of the bills. The point at which the cap takes over is found by solving the middle stage for the bills at which your share first equals the maximum: deductible + (maximum − deductible) ÷ coinsurance. With no coinsurance there is no such point, because your share never grows past the deductible. The total for the year = the monthly premium × 12 + your share. The worst case = the monthly premium × 12 + the full out-of-pocket maximum, since that is where your share stops however large the bills get.
Example
A plan charges $240 a month, carries a $2,000 deductible and a 20% coinsurance share, and caps you at $8,000 for the year. Expecting $6,000 of covered bills, you pay the first $2,000 in full and 20% of the remaining $4,000, which is $800 — your share is $2,800 and the plan pays $3,200. Add $2,880 of premiums and the year costs $5,680. The cap would not take over until $32,000 of bills, and the worst the year could be is $10,880. Walking up the schedule makes the shape visible: at $1,000 of bills you pay all $1,000 and the plan pays nothing; at $5,000 you pay $2,600; at $15,000 you pay $4,600 while the plan pays $10,400; and at $50,000 and $150,000 alike you pay $8,000 and the plan absorbs the rest. Raise the maximum to the 2026 legal limit of $10,600 for self-only coverage and the ordinary year is unchanged at $2,800, but the cap now takes over at $45,000 of bills and the worst case rises to $13,480.
Definitions
- Premium
- What you pay each month to hold the plan. It never counts toward the out-of-pocket maximum, which is why the page tracks it separately and adds it back only in the totals.
- Deductible
- What you pay in full before the plan starts contributing. It resets each plan year and, on most plans, counts toward the out-of-pocket maximum.
- Coinsurance
- Your percentage share of covered costs between the deductible and the maximum. A 20% share means the plan pays 80% of everything in that middle stage.
- Out-of-pocket maximum
- The most the plan can charge you for covered in-network care in a plan year. For 2026 the law caps it at $10,600 for self-only coverage and $21,200 for a family on any non-grandfathered plan.
- Medical bills you expect
- The total your providers would bill, before insurance — not your share. Using your share here would double-count the deductible.
- Cap takes over at
- The level of billed care at which your cost sharing reaches the maximum and stops growing. Shown as a dash when no coinsurance applies, because your share can never climb that far.
- Worst case, all in
- Premiums for the year plus the full out-of-pocket maximum: the most an in-network year can cost you, and the figure worth planning your savings around.
- Balance billing
- The difference between what an out-of-network provider charges and what your plan allows. It generally sits outside the out-of-pocket maximum entirely.
Frequently asked questions
What is the most my health plan can cost me in a year?
Your premiums plus your out-of-pocket maximum, for in-network covered care. On this page's defaults — $240 a month, a $2,000 deductible, 20% coinsurance and an $8,000 maximum — that ceiling is $10,880, being $2,880 of premiums and the $8,000 cap. Nothing about the amount of care changes it: at $50,000 of bills and at $150,000 of bills the answer is the same $10,880.
At what point does the out-of-pocket maximum start protecting me?
Later than most people assume. On the defaults the cap takes over at $32,000 of covered bills, because you pay the $2,000 deductible in full and then 20% of everything after it, and 20% of $30,000 is the remaining $6,000 of the cap. At $6,000 of bills your share is $2,800 — nowhere near the ceiling. The cap is a backstop against a catastrophic year rather than a limit you brush against in an ordinary one.
Do premiums count toward the out-of-pocket maximum?
No, and this is the most common misunderstanding about the figure. The maximum covers deductibles, copays and coinsurance for covered in-network services. Premiums never count, and neither do balance bills, out-of-network care in most plans, or anything the plan classifies as non-covered. That is why the page reports your share of the bills and the total for the year as two separate figures: on the defaults, $2,800 of cost sharing but $5,680 all in.
What is the legal limit on an out-of-pocket maximum in 2026?
For plan year 2026 a non-grandfathered plan may not cap you above $10,600 for self-only coverage or $21,200 for other than self-only, under the Marketplace Integrity and Affordability final rule at 90 FR 27074. That is a ceiling on the ceiling, not a typical figure — the default plan here caps at $8,000, well inside it. A Silver Marketplace plan bought with cost-sharing reductions is capped lower still, at $3,500 for households up to 200% of the poverty line and $8,450 up to 250%, on self-only coverage.
What does a bad year actually look like?
Run the defaults at $40,000 of bills. Your share is $8,000, the plan pays $32,000, and the year costs you $10,880 with premiums — the ceiling exactly, because $40,000 of bills is past the $32,000 point where the cap takes over. Compare that with the light year at $1,500 of bills, where you pay all $1,500 yourself, the plan pays nothing, and the year costs $4,380. The spread between a quiet year and a catastrophic one, on the same plan, is about $6,500.
Would a higher out-of-pocket maximum change much?
It raises the ceiling and pushes the protection further away, and it does both by the same amount. Take the defaults up to a $10,600 maximum — the 2026 legal limit for self-only coverage — and the ordinary year does not move at all: at $6,000 of bills you still pay $2,800. But the point at which the cap takes over moves from $32,000 to $45,000 of bills, and the worst case rises from $10,880 to $13,480. A higher maximum is invisible until the year you need it.