The ACA caps what one person can pay out of pocket each plan year.
Non-grandfathered group health plans must cap in-network essential health benefit cost sharing each year. Here is what counts, the 2026 and 2027 limits, and how HSA rules differ.
Eight Pages On Plan Cost Limits.
General information, not legal or tax advice. Each page links to the plan or tax rule it relies on.
The Out-of-Pocket Maximum, Explained
What the cap means for an employee, in plain terms.
Deductible vs. Out-of-Pocket Maximum
Two different numbers on the same plan and how they work together.
Out-of-Pocket Exposure Calculator
See the worst-case year for an employee on a given plan.
Renewal Cost-Sharing Calculator
Model who pays when a renewal comes in higher.
HDHP and HSA Limits for 2026 and 2027
The IRS figures that govern HSA-qualified plans.
Section 223: HSAs and the HDHP Rules
The tax code rules behind the HSA out-of-pocket limit.
Affordable Care Act for Employers
The employer mandate, reporting and other ACA duties.
Employee Notices You Must Provide
What employers are required to hand to employees.
What The Law Requires.
Section 2707(b) of the Public Health Service Act, 42 U.S.C. 300gg-6(b), says a group health plan must ensure that annual cost sharing does not exceed the limits in 42 U.S.C. 18022(c)(1). HHS sets the dollar amounts under 45 CFR 156.130. The self-only limit is the 2014 amount raised each year by a premium adjustment percentage. The limit for any other coverage is twice the self-only figure, and increases are rounded down to a multiple of $50.
In practice the cap works as a ceiling on one plan year. Once a covered person has paid that much in qualifying cost sharing, the plan must pay covered in-network essential health benefits in full for the rest of the year.
Grandfathered plans are outside this rule. The grandfathering regulation, 29 CFR 2590.715-1251, lists section 2707 among the provisions that do not apply to grandfathered health plans. If your plan lost grandfathered status after a benefit or cost change, assume the cap applies and confirm with the carrier.
What Counts And What Does Not.
The statute defines cost sharing in 42 U.S.C. 18022(c)(3). It includes deductibles, coinsurance, copayments and similar charges, plus other required spending that qualifies as a medical expense for covered essential health benefits.
Three things are excluded by that definition: premiums, balance billing by out-of-network providers, and spending on services the plan does not cover. The regulation adds that cost sharing for out-of-network benefits is not required to count toward the limit, so a plan may let it sit outside the cap. Because the limit is tied to essential health benefits, a service that is not one of them is not part of the test either.
The takeaway for employees: the cap is real but narrow. A person who goes out of network, or who is billed above the allowed amount, can spend well past it.
The Embedded Individual Limit.
For other-than-self-only coverage the plan-wide cap is twice the self-only limit. That does not mean one family member can be asked to pay the whole family amount. In a May 8, 2015 FAQ, CMS explained that under the 2016 Notice of Benefit and Payment Parameters (80 Fed. Reg. 10750) the self-only limit applies to each individual, even one enrolled in a family plan. The per-person amount may be no higher than the self-only limit.
A family plan can therefore have two ceilings working together: one for each person and one for the family as a whole. The FAQ was written for 2016, but the self-only limit it points to is the one published each year, so it moves with the figures below. Ask your carrier to show the per-person cap in the plan documents, because a plan with a single high family deductible and no individual cap is a common design problem.
How The HSA Limit Differs.
A separate limit sits in the tax code. To be an HSA-qualified high deductible health plan, 26 U.S.C. 223(c)(2)(A) caps the annual deductible plus other required out-of-pocket expenses, again excluding premiums. The IRS adjusts that cap each year. The two tests have different jobs: the ACA limit is a requirement on the plan, and the IRS limit is a condition of HSA eligibility for the people covered.
The practical effect is that the lower number usually controls. For self-only coverage the IRS figure is below the ACA figure, so an HSA-qualified plan rarely has room to use the full ACA cap. For family coverage the IRS family limit is above the ACA individual limit, which is why the embedded individual cap matters on family HDHPs. CMS addressed that overlap in the same 2015 FAQ.
The 2026 And 2027 Limits.
Checked against CMS and IRS documents on October 28, 2026. Confirm against your carrier documents for your plan year.
Plan year 2026, ACA limit: $10,600 self-only and $21,200 other than self-only, as restated in CMS guidance dated January 29, 2026.
Plan year 2027, ACA limit: $12,000 self-only and $24,000 other than self-only, published by CMS in its 2027 premium adjustment percentage guidance on January 29, 2026.
Calendar year 2026, HDHP limit: $8,500 self-only and $17,000 family, from IRS Revenue Procedure 2025-19.
Calendar year 2027, HDHP limit: $8,700 self-only and $17,400 family, from IRS Revenue Procedure 2026-24.
HHS publishes the ACA limits through the annual Notice of Benefit and Payment Parameters or, under 45 CFR 156.130(e), in January guidance on the premium adjustment percentage. The IRS publishes the HDHP figures in a revenue procedure each spring. Check both each year when you review a renewal.
Checking Your Own Plan.
At each renewal, compare the plan summary to the limit for the plan year it covers, including the per-person cap on any family tier. Look at pharmacy cost sharing as well as medical, since both count when they are essential health benefits. If a number looks high, ask the carrier in writing to confirm how it meets the limit.
Our team reviews these figures as part of renewal work and can walk through the plan documents with you. General information, not legal advice.
Laws And Sources
42 U.S.C. 300gg-6: Public Health Service Act section 2707, including the cost-sharing limit in subsection (b).
42 U.S.C. 18022: Essential health benefits, the annual cost-sharing limit in subsection (c)(1) and the definition of cost sharing in (c)(3).
45 CFR 156.130: HHS regulation on the annual limitation on cost sharing, out-of-network cost sharing and the premium adjustment percentage.
29 CFR 2590.715-1251: Grandfathered health plan rules, including the provisions that do not apply to them.
26 U.S.C. 223: HSA rules, including the HDHP out-of-pocket limit in subsection (c)(2)(A).
CMS, 2027 Premium Adjustment Percentage Guidance: The 2027 limits of $12,000 and $24,000 and the 2026 figures, dated January 29, 2026.
CMS, Embedded Self-Only Annual Limitation FAQs: May 8, 2015 guidance on the per-person limit in family coverage.
IRS Revenue Procedure 2025-19: 2026 HSA and HDHP limits.
IRS Revenue Procedure 2026-24: 2027 HSA and HDHP limits.
General information, not legal or tax advice.
Quick Answers.
Brief answers to what employers ask about the annual limit, each linked to a fuller page.
What is the ACA out-of-pocket maximum for 2026 and 2027?
For plan year 2026 the limit is $10,600 for self-only coverage and $21,200 for other coverage. For 2027 it is $12,000 and $24,000, per CMS guidance dated January 29, 2026.
Do all employer health plans have to follow the limit?
No. Grandfathered plans are exempt under 29 CFR 2590.715-1251. Non-grandfathered group health plans must meet it under 42 U.S.C. 300gg-6(b).
Do premiums count toward the out-of-pocket maximum?
No. The statute excludes premiums, out-of-network balance billing and spending on services the plan does not cover. Deductibles, coinsurance and copayments for covered essential health benefits count.
What is the embedded individual limit on a family plan?
It is the rule that the self-only limit applies to each person on a family plan, so no one member pays more than that amount even when the family limit is higher. CMS explained it in a May 8, 2015 FAQ.
How does the HSA out-of-pocket limit differ from the ACA limit?
The IRS limit in 26 U.S.C. 223(c)(2)(A) decides whether a plan is HSA-qualified: $8,500 self-only and $17,000 family for 2026, and $8,700 and $17,400 for 2027. The ACA limit is a separate plan requirement, and the lower one usually controls.
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