Some bills can still be yours after you reach your out-of-pocket maximum: premiums, services your plan does not cover, most out-of-network care, care in a new plan year, and your share of the care that got you to the limit, even if its bill comes later. A bill for covered in-network care from after the day you reached the limit is worth asking about, because HealthCare.gov says that once you reach it your plan pays the full cost of covered benefits for the rest of the plan year.
Five bills that can still be yours after the out-of-pocket maximum
- Premiums. You pay them whether you get care or not, and they never count toward the limit.
- Services your plan does not cover. What you spend on them does not count either.
- Most out-of-network care. There is an exception for care the No Surprises Act protects, such as emergency care.
- Care in a new plan year. The limit starts over, and your plan year may not match the calendar year.
- Your share of the care that got you to the limit. It already counted, and its bill can still arrive after the day you reached the limit.
What is the out-of-pocket maximum?
HealthCare.gov defines it as the most you have to pay for covered services in a plan year. Your deductible, copays and coinsurance for in-network care count toward it. Once you reach it, your plan pays the full cost of covered benefits for the rest of that plan year.
Marketplace plans and job-based plans that are not grandfathered must keep this limit at or under a federal cap, according to HealthCare.gov and the U.S. Department of Labor. For plan years that start in 2026, the cap is $10,600 for one person and $21,200 for a family. For plan years that start in 2027, it is $12,000 and $24,000. Ask your employer if you are not sure whether your plan is grandfathered. Your plan's own limit may be lower. In a family plan, no one person pays more than the one-person limit, according to the U.S. Department of Labor.
On Medicare? These caps are not yours. Medicare.gov says Original Medicare has no yearly limit on what you pay out of pocket, unless you have extra coverage such as a Medigap policy. Each Medicare Advantage plan sets its own yearly limit.
What does the out-of-pocket maximum not cover?
HealthCare.gov lists costs that do not count toward the limit:
- Your monthly premiums. You pay these whether you get care or not.
- Services your plan does not cover.
- Out-of-network care. This usually does not count. One exception: for care the No Surprises Act protects, such as emergency care, your share has to count toward your in-network limit.
- Amounts above the allowed amount. HealthCare.gov says costs above the allowed amount that a provider may charge do not count. It also says an in-network provider may not balance bill you for covered services, so a charge like that from an in-network provider is worth asking about.
A new plan year also brings a new limit. Your plan year may not match the calendar year, so check when yours starts.
Count your year so far
Type your plan’s figures. This count also adds each bill you got the full list for on this device. Nothing you type is sent or saved.
Only your insurer’s figure counts. Compare it with your latest EOB, and keep every appeal date and deadline you have.
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Check my bill, freeHow to check your EOB
Find the Explanation of Benefits (EOB) from your insurer for this visit.
- Check the date of service. Is it in the plan year when you reached the limit?
- Check what the EOB says you may owe. If it still shows a share for covered in-network care after you reached the limit, that is worth asking about.
- Look for notes saying a service was not covered or was out of network.
- Find how much had counted toward your limit before this visit. An EOB for this visit may show a figure that already includes this bill. If it is not there, call the number on your insurance card.
- Compare the bill with the EOB. If the bill asks for more, ask why.
What to ask
If the bill came months after the visit, our guide on a medical bill that comes months later lists the dates to ask for.
Call your insurer first:
- "How much has counted toward my out-of-pocket maximum this plan year, and when did I reach it?"
- "Was this claim processed before or after I reached it?"
- "Was any part treated as out of network or not covered, and why?"
Then call the provider's billing office:
- "Was this bill sent before my insurer finished processing the claim?"
- "Can you hold my account while I check with my insurer?"
One sentence to say on the phone:
"I reached my out-of-pocket maximum on [date], so can you check whether this claim was processed with that in mind before I pay?"
Only your insurer and the provider can confirm what you owe. Write down who you spoke to and when. If the answers do not settle it, our guide on how to dispute a medical bill has the next steps, in order.
MedBillCheckup has a money check for your yearly maximum. You type in your plan's limit and how much had counted toward it before this visit, and it compares them with your share of this bill.
If you already paid a share the plan should have covered, the difference may be a credit on your account. Our guide on paying more than you owed on a medical bill shows how to ask for it back, and the free refund request letter writes the request.
Open your bill in MedBillCheckup: take a photo or choose the PDF. It is read on your device and the file stays with you. The free check shows how many things are worth asking about, and the largest amount you may get back or may not owe. The full list is paid. With it, we will compare your share of this bill with what is left of your yearly maximum and list the questions to ask your insurer and the billing office.
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Questions about this guide
I met my out-of-pocket max, so why am I still getting bills?
Five kinds of bills can still be yours: premiums, services your plan does not cover, most out-of-network care, care in a new plan year, and your share of the care that got you to the limit, if its bill comes late. A bill for covered in-network care from after the day you reached the limit is worth asking about. Ask your insurer when you reached it and whether the claim was processed with that in mind.
Do my monthly premiums count toward the out-of-pocket maximum?
No. Premiums are what you pay to keep the plan. HealthCare.gov lists them among the costs that do not count toward the limit.
Does the out-of-pocket maximum start over?
Yes. It is a limit for one plan year, so care in a new plan year counts toward a new limit. Your plan year may not match the calendar year. Your plan documents or your employer can tell you when it starts.
Why am I still paying at the pharmacy after reaching my out-of-pocket maximum?
Your plan may split its yearly limit. The U.S. Department of Labor says plans may use separate out-of-pocket limits, as long as their combined amount does not go over the federal yearly limit. If your plan has a separate limit for prescription drugs, reaching the limit for medical care may not end what you pay at the pharmacy. HealthCare.gov also lists what you spend on services your plan does not cover among the costs the limit leaves out. Ask your insurer which limit this cost counts toward and how much of it is left.
What if the out-of-network care was a surprise bill?
For care the No Surprises Act protects, such as emergency care at an out-of-network hospital, your plan has to count your share toward your in-network deductible and out-of-pocket maximum.
Sources
- HealthCare.gov: Out-of-pocket maximum/limit, glossary
- HealthCare.gov: Plan year, glossary
- Centers for Medicare & Medicaid Services: Requirements related to surprise billing, Part I interim final rule
- U.S. Department of Labor: FAQs about Affordable Care Act implementation (Part XII)
- U.S. Department of Labor: FAQs about Affordable Care Act implementation (Part XVIII)
- Centers for Medicare & Medicaid Services: Premium adjustment percentage, maximum annual limitation on cost sharing and required contribution percentage for the 2027 benefit year
- U.S. Department of Labor: FAQs about Affordable Care Act implementation (Part XXVII)
- HealthCare.gov: Balance billing, glossary
- Medicare.gov: Medicare costs
Related guides
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Free tools
- Itemized bill request letter
Ask the provider for every charge, line by line.
- Refund request letter
Ask for a credit balance back when you paid more than your share.
- Financial assistance request letter
Ask a hospital for its financial assistance policy and application form.
- Charity care check
See whether you may qualify for a hospital’s financial assistance.
- Letter to a collection agency
Dispute a medical debt, or ask the agency for verification.
- Medical bill dispute letter
Ask the billing office about the charges you type.
- Insurance claim file request letter
Ask a health plan for the documents behind a decision on a claim.
- Medical bill code lookup
Medicare’s name for a drug, supply or equipment code on your bill.
- Health money dates 2027
Open enrollment, FSA, Medicare and tax dates for 2027, each with its source.
- Medical bill glossary
The words and abbreviations on bills and EOBs, explained.