Example plan: $2,000 deductible, 20% coinsurance, $6,000 out-of-pocket maximum. Premiums are separate and never count.
| Covered in-network care in the year | You pay | Plan pays | Where you are |
|---|---|---|---|
| $500 | $500 | $0 | Inside the deductible |
| $2,000 | $2,000 | $0 | Inside the deductible |
| $5,000 | $2,600 | $2,400 | Coinsurance phase |
| $12,000 | $4,000 | $8,000 | Coinsurance phase |
| $22,000 | $6,000 | $16,000 | At the out-of-pocket maximum |
| $40,000 | $6,000 | $34,000 | At the out-of-pocket maximum |
How to read the table
- At $500 of care you are still in the deductible, so you pay all $500.
- At $5,000 you pay the $2,000 deductible plus 20% of the remaining $3,000: $2,000 + $600 = $2,600.
- The maximum is reached when $2,000 + 20% of the rest equals $6,000, which happens at $22,000 of care.
- At $40,000 you still pay only $6,000 for covered in-network care; the plan pays $34,000.
Key differences
| Deductible | Out-of-pocket maximum | |
|---|---|---|
| What it is | Start-up amount you pay first | Yearly cap on what you pay |
| Includes the deductible? | It is the first part | Yes, it counts toward it |
| Resets | Each plan year | Each plan year |
| 2027 HDHP rules | At least $1,750 / $3,500 | At most $8,700 / $17,400 |
Plans differ; this uses the simple model of the calculator (copays are separate). Source for definitions: HealthCare.gov deductible and out-of-pocket maximum.
Related: what counts toward the maximum · coinsurance vs copay · plan costs hub · ACA maximum 2027.
This is general information, not tax or insurance advice. Confirm details with your plan documents, the IRS and a qualified professional.
General education, not insurance, tax or legal advice. Figures from IRS and HHS publications; confirm with your plan documents.