What is the out-of-pocket maximum?

The out-of-pocket maximum is the most you will pay for covered services in a plan year. For 2026, the ACA limit is $9,450 for individual plans and $18,900 for family plans. After reaching this amount, insurance pays 100% of covered services.

Do copays count toward the deductible?

It depends on your plan. Some plans count copays toward the deductible and out-of-pocket maximum, while others do not. Check your Summary of Benefits and Coverage (SBC) for details.

Why You Still Owe Money After Insurance Pays

Insurance Does Not Mean Free

Health insurance is designed to share costs between you and the insurance company — not eliminate them entirely. Even after your insurer processes a claim, you are typically responsible for some portion of the bill. The amount you owe depends on your plan's cost-sharing structure: your deductible, copay, and coinsurance rates. Understanding these three numbers is the key to predicting what any medical visit will cost you.

Your Deductible Comes First

Your deductible is the amount you must pay out of pocket before your insurance starts paying. If your plan has a $2,000 deductible and you have not met it yet, you will pay the first $2,000 of covered medical costs yourself. Most plans reset the deductible annually on January 1. Early-year medical visits tend to cost more because patients have not yet met their deductible. Some services (like preventive care) are covered before the deductible.

Copays: Flat Fees Per Visit

A copay is a fixed dollar amount you pay for a specific service — for example, $30 for a primary care visit or $50 for a specialist. Copays are usually paid at the time of service and do not count toward your deductible on all plans (check your plan documents). Emergency room copays are typically much higher ($200-$500) and may be waived if you are admitted to the hospital.

Coinsurance: Your Percentage of the Bill

After you meet your deductible, coinsurance kicks in. This is the percentage of the bill you share with your insurer — commonly 20% for the patient and 80% for the insurer. On a $10,000 hospital bill after deductible, you would owe $2,000 in coinsurance. Coinsurance continues until you reach your out-of-pocket maximum, at which point insurance covers 100% of covered services for the rest of the plan year.

Out-of-Network Costs

If you see an out-of-network provider, your costs can be significantly higher. Out-of-network services may have a separate (higher) deductible, higher coinsurance rates (often 40-50% instead of 20%), and balance billing risk. The No Surprises Act protects you from surprise out-of-network bills in emergency situations and at in-network facilities, but planned out-of-network care remains expensive.

How to Estimate Your Costs

Before any non-emergency service, call your insurance company and ask: Has my deductible been met? What is my copay or coinsurance for this service? Is this provider in-network? What is the estimated allowed amount? Multiply the allowed amount by your coinsurance rate to estimate your share. This five-minute call can prevent billing surprises.