| Item | Counts toward the maximum? |
|---|---|
| Deductible (covered, in-network) | Yes |
| Copays (covered, in-network) | Yes |
| Coinsurance (covered, in-network) | Yes |
| Monthly premiums | No |
| Services your plan does not cover | No |
| Out-of-network balance bills above the allowed amount | Generally no |
| Out-of-network care at a higher cost share | Depends on the plan; many plans have a separate, higher out-of-network maximum |
| Penalties for skipping required prior authorization | Often no, check the plan |
| Emergency and certain surprise out-of-network bills | Treated as in-network cost sharing under federal rules (No Surprises Act) for covered care |
Worked example: why total spending can exceed the maximum
| Item | Amount |
|---|---|
| In-network covered care: $30,000 (plan: $2,000 deductible, 20%, $6,000 maximum) | $6,000 |
| Out-of-network balance bill above allowed amount | $3,000 |
| Non-covered service | $1,500 |
| Premiums for the year | $4,800 |
| Total cash out the door | $15,300 |
| Counted toward the out-of-pocket maximum | $6,000 |
So the “$6,000 maximum” is a cap on your covered in-network cost sharing, not on everything you spend on health in a year. Your Summary of Benefits and Coverage lists the exclusions.
Other things that change the count
- On a family plan, each person’s costs add to the family total; see embedded vs non-embedded.
- If you change plans mid-year, the new plan starts at zero (COBRA keeps the old plan and its totals).
- Some plans count manufacturer copay assistance differently; ask your plan.
Sources: HealthCare.gov; CMS No Surprises Act. Checked October 18, 2026.
Related: deductible vs maximum · ACA out-of-pocket maximum 2027 · plan costs hub.
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.