What counts toward the out-of-pocket maximum?
Generally the deductible, copays and coinsurance for covered, in-network care count. Premiums, services the plan does not cover and, in most plans, out-of-network care do not.
What is behind the short answer.
The short answer is above. These are the details that decide it for a specific plan.
What usually counts
Deductible, copays and coinsurance paid for covered in-network services.
What usually does not
Monthly or per-paycheck premiums, services excluded from the plan, and charges above the allowed amount.
The network caveat
Out-of-network care often has a separate, higher limit or no limit at all, depending on the plan type.
Where to confirm
The plan documents and the summary of benefits and coverage state exactly what is counted. Ask before assuming.
What the rules say.
The figures and requirements below come from the federal sources cited at the end of this section. General information, not legal advice.
The 2026 federal limit
For 2026, the annual limit on cost sharing for non-grandfathered group health plans is 10,600 dollars for self-only coverage and 21,200 dollars for other-than-self-only coverage. HHS revised these from the 10,150 and 20,300 dollars first published for 2026.
It applies to each person on a family plan
Even on family coverage, no single person can be asked to pay more than the self-only limit toward covered in-network essential health benefits.
It covers in-network essential health benefits
The federal limit applies to covered in-network essential health benefits. Premiums, out-of-network charges and services the plan does not cover sit outside it.
A separate ceiling for HSA-qualified plans
A high-deductible plan paired with a Health Savings Account must keep out-of-pocket costs at or below 8,500 dollars for self-only and 17,000 dollars for family coverage in 2026.
Sources: 42 U.S.C. 18022
We read the counting rules so employees do not have to.
The exact list of what counts varies by plan. We confirm it for each option we compare.
Related pages.
The Out-of-Pocket Maximum, Explained in Plain Terms
The out-of-pocket maximum is the most an employee pays in a plan year for covered, in-network care.
What is the difference between a deductible and an out-of-pocket maximum?
The deductible is what an employee pays for covered care before the plan starts sharing the cost.
Why the Provider Network Is Part of the Plan
The same plan can cost very different amounts depending on which doctor or hospital an employee uses.
Avoiding Group Health Insurance Plan Confusion
The full guide to helping employees understand their group health plan.
Questions that come up next.
Short answers to the questions employees ask after this one. Each links to its own page.
Is a high-deductible plan always the cheaper choice?
No. A high-deductible plan usually has a lower premium, but it can cost more in a year with significant care. The right choice depends on how much care the employee expects to use and whether they can cover the deductible if they need to.
Why did we get a bill after a visit that only had a copay?
Because the copay usually covers the visit itself and not everything billed around it. Lab work, imaging, a procedure, a facility fee or an out-of-network provider can each be billed separately.
Do copays count toward the deductible?
It depends on the plan. On some plans copays count toward the deductible and on others they do not. Copays generally do count toward the out-of-pocket maximum for covered in-network care, but confirm in your plan documents.
Ready? Send us your renewal, or talk it through with someone first. No cost, no obligation.
General information about group health plan terms, not legal or tax advice. Plan-specific questions belong with the plan documents and the carrier.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents, two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
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