A coinsurance maximum is the cap on the total amount of cost-sharing you pay out of your own pocket during a plan year. Once your combined spending on deductibles, coinsurance, and copays hits that limit, your insurance covers 100% of remaining covered services. For 2025, federal law caps this limit at $9,200 for an individual and $18,400 for a family on Marketplace plans.
You’ll also see this called an “out-of-pocket maximum” or sometimes a “stop-loss provision,” especially in employer-sponsored plans. These terms all describe the same protection: a dollar ceiling that prevents your medical costs from spiraling indefinitely in a single year.
How Coinsurance Works Before You Hit the Max
To understand the maximum, it helps to see the full sequence of how you pay for care in a given year. Your costs move through stages, and each stage has its own rules.
First, you pay your deductible. This is a flat dollar amount (often $1,500 to $3,000 for an individual plan) that you cover entirely before your insurer starts sharing costs. If you have a $2,000 deductible and get a $500 lab bill in February, you pay the full $500 yourself because you haven’t yet spent $2,000 on care that year.
Once you meet your deductible, coinsurance kicks in. Your plan might cover 80% of each bill while you pay 20%. That 20% is your coinsurance. So on a $1,000 procedure after meeting your deductible, you’d owe $200 and your insurer would pay $800.
You keep paying that percentage on every covered service until all your out-of-pocket spending for the year, including your deductible, coinsurance, and any copays, reaches the coinsurance maximum. At that point your insurer pays 100% of covered services for the rest of the plan year.
A Dollar Example From Start to Finish
Say your plan has a $2,000 deductible, 20% coinsurance, and a $6,850 out-of-pocket maximum. Early in the year you have surgery that costs $30,000.
You first pay $2,000 (your deductible). That leaves $28,000, of which you owe 20%, or $5,600. But $2,000 plus $5,600 equals $7,600, which exceeds your $6,850 maximum. So you’d actually pay only $4,850 in coinsurance (bringing your total to $6,850), and your insurer would cover the rest. Every covered bill after that for the remainder of the plan year costs you nothing.
Federal Limits for 2025 and 2026
The Affordable Care Act sets a ceiling on how high any Marketplace plan’s out-of-pocket maximum can go. Plans can set their limit lower than the federal cap, but not higher.
- 2025: $9,200 for an individual, $18,400 for a family
- 2026: $10,600 for an individual, $21,200 for a family
These caps adjust annually with inflation. Employer-sponsored plans that aren’t sold on the Marketplace generally follow the same federal limits, though some large employers voluntarily set lower maximums as a benefit to employees.
What Doesn’t Count Toward Your Maximum
Not every dollar you spend on healthcare counts toward hitting that cap. Several common expenses are excluded:
- Monthly premiums: The amount you pay each month just to have the plan never counts.
- Out-of-network charges: If you see a provider outside your plan’s network, those costs typically don’t accumulate toward your in-network maximum. Some PPO plans have a separate, higher out-of-network maximum, but many plans simply don’t cap out-of-network spending at all.
- Balance billing: If a provider charges more than what your plan considers the approved amount, you can be billed for the difference. That extra cost usually doesn’t count.
- Non-covered services: Anything your plan explicitly doesn’t cover (cosmetic procedures, for example) won’t count toward the limit no matter how much you spend.
This is why checking whether a provider is in-network matters so much. You could spend thousands on out-of-network care and still be at $0 progress toward your in-network maximum.
How HMO and PPO Plans Handle It Differently
Your plan type affects how the coinsurance maximum works in practice, mainly because of network rules.
HMO plans require you to stay inside their provider network except in emergencies. If you get non-emergency care from an out-of-network provider, you pay the full cost yourself, and none of it counts toward your maximum. The upside is that HMOs often have lower out-of-pocket maximums and lower coinsurance percentages, since they negotiate tighter rates with a smaller network.
PPO plans let you see providers both in and out of network, but with very different cost-sharing. In-network visits apply to your in-network maximum as expected. Out-of-network visits may apply to a separate, higher out-of-pocket maximum, or they may not be capped at all. A PPO plan might have a $6,000 in-network maximum and a $12,000 out-of-network maximum, meaning you’d need to spend far more before reaching full coverage for out-of-network care.
The Maximum Resets Every Year
Your progress toward the coinsurance maximum resets to zero at the start of each plan year. For most employer plans, the plan year runs January through December. Marketplace plans also follow the calendar year. Some employer plans use a different start date (like July 1), so check your benefits summary if you’re unsure.
This reset matters most if you’re planning a major procedure. If you’ve already spent $7,000 toward a $9,200 maximum in October, scheduling additional care before December 31 means your insurer picks up nearly all of it. Waiting until January restarts the clock, and you’d pay your full deductible and coinsurance again from scratch.
Why the Number on Your Plan May Differ
The federal limits are ceilings, not standard amounts. Plans vary widely in where they set the actual maximum. A Bronze plan on the Marketplace might set it right at the federal cap of $9,200, while a Gold or Platinum plan might set it at $4,000 or $5,000. Generally, plans with higher monthly premiums have lower out-of-pocket maximums, and vice versa.
When comparing plans, look at the deductible, the coinsurance percentage, and the out-of-pocket maximum together. A plan with a low deductible but high coinsurance percentage can still result in high total costs before you hit the cap. The maximum is your worst-case scenario for covered, in-network care in a given year, so it’s the single most important number if you’re worried about a major health event.