Recovery Numbers

Out-of-Pocket Maximum Calculator

Estimate how much you could pay in a plan year before your health insurance covers 100% of covered services. Free, instant, no data stored.

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Determines the 2025 ACA OOP maximum limit: $9,450 (individual) or $18,900 (family).

The amount you pay in full before insurance starts paying. Check your Summary of Benefits and Coverage (SBC).

Common coinsurance rates: 80/20 → enter 20. 70/30 → enter 30. After your deductible, you pay this % of covered costs until you hit the OOP max.

Total billed by in-network providers before insurance adjustments. Use last year's EOBs as a guide, or estimate conservatively for a worst-case view.

Cost Estimate

Estimated annual OOP cost —
Distance to OOP maximum —
2025 OOP maximum $9,450 / $18,900
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How the out-of-pocket maximum works

The out-of-pocket maximum (OOP max, sometimes written "opp max") is the most you will pay in a plan year for covered in-network services. Once you hit it, your insurance pays 100% of covered costs for the rest of the year. The ACA sets a federal ceiling on OOP maxes each year — in 2025, that ceiling is $9,450 for individual coverage and $18,900 for family coverage. Your plan's actual OOP max may be lower than the federal ceiling but cannot be higher.

Your spending counts toward the OOP max in this order:

  1. Deductible — you pay 100% of covered costs until you reach your deductible.
  2. Coinsurance — after the deductible, you pay your coinsurance share (e.g., 20%) of covered costs.
  3. Copays — fixed-dollar amounts per visit. Whether copays count toward the OOP max depends on your plan; many plans count them.
  4. OOP max hit — once your total paid equals your OOP max, the insurer pays 100% for covered services.

What does NOT count toward your OOP max

  • Monthly premiums — these are never counted.
  • Out-of-network care (unless your plan has combined in/out-of-network tracking).
  • Non-covered services (cosmetic procedures, dental, vision on medical plans, etc.).
  • Amounts above the allowed charge — if your provider bills $500 and the insurer allows $300, only $300 counts.

Frequently asked questions

What is the 2025 OOP maximum?

The 2025 ACA out-of-pocket maximum is $9,450 for self-only (individual) coverage and $18,900 for family coverage. This is the federal ceiling; your plan may have a lower OOP max. High-deductible health plans (HDHPs) have a separate OOP max that qualifies for HSA pairing — $8,300 individual / $16,600 family in 2025.

Does my deductible count toward the OOP max?

Yes. Your deductible is part of your out-of-pocket costs and counts toward the OOP max. If your deductible is $2,000 and your OOP max is $5,000, you only need to pay $3,000 more in coinsurance and copays after meeting the deductible before coverage becomes 100%.

Do copays count toward the OOP max?

On most ACA-compliant plans, copays count toward the OOP max. However, some employer plans and grandfathered plans may not count copays. Check your Summary of Benefits and Coverage (SBC) document — it must disclose this. If you have a lot of routine visits, it is worth confirming your copays accumulate.

How does the family OOP max work?

Family plans typically have two limits: an individual embedded limit and a family-level limit. An individual within the family plan cannot be made to pay more than the individual embedded limit (e.g., $9,450) before that person's costs are covered 100%, even if the family total has not hit the family limit. This protects high-utilization members within a family.

Can an HSA reduce what I pay out of pocket?

Yes. If you are on an HDHP, you can contribute to an HSA tax-free and use those funds to pay your deductible, coinsurance and copays. This effectively reduces your after-tax OOP cost without changing the OOP max dollar amount. See the HSA vs FSA comparison calculator for a tax-savings breakdown.