Short answer: The amounts you pay out of pocket for covered, in-network care: your deductible, copayments, and coinsurance. Once those add up to your plan’s out-of-pocket maximum, the plan pays 100% of covered benefits for the rest of the plan year. Premiums, out-of-network care, and services your plan does not cover do not count.
Your out-of-pocket maximum is 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 cost of covered benefits. For 2026, a Marketplace plan’s out-of-pocket limit cannot exceed $10,600 for one person or $21,200 for a family.
Some spending never counts toward the limit. Federal rules define cost-sharing as deductibles, coinsurance, and copayments for essential health benefits, and care from an out-of-network provider is not required to count toward the annual limitation on cost sharing. So out-of-network bills, balance-billing charges, and amounts for non-covered services can continue even after you reach your in-network maximum.