2026 Maximum Out-of-Pocket Changes: Which Plans Updated Their Limits and What It Means for You

Why the maximum out-of-pocket matters

Your maximum out-of-pocket is your plan’s annual “safety cap” on what you pay for covered care after you meet deductibles and pay copays or coinsurance. Once you hit that limit, many plans cover additional in-network, covered costs for the rest of the year.

That cap matters because it helps you estimate your worst-case year for healthcare spending, especially if you’re managing ongoing conditions, planning procedures, or taking high-cost medications.

It also matters because many plans reset this number every January, and some plans have more than one cap (for example, a medical cap and a prescription drug cap).

Quick takeaways for 2026

• A new plan year can mean a new out-of-pocket cap, even if you stay on the same plan.
• ACA Marketplace plans and most employer plans have a federally defined maximum that updated for 2026.
• Medicare Part D drug coverage has a new annual out-of-pocket maximum for covered prescription drugs in 2026.
• Medigap Plan K and Plan L have updated annual out-of-pocket limits for 2026.
• If you have Medicare Advantage, your plan’s medical out-of-pocket maximum can change from year to year, so it’s important to check your 2026 plan documents.

Plans that changed their maximum out-of-pocket for 2026

ACA Marketplace plans and most employer plans (medical services)

If you have an ACA-compliant plan (Marketplace coverage and most non-grandfathered employer plans), there is a federal maximum annual limitation on cost sharing that plans generally cannot exceed for in-network essential health benefits.

For plan year 2026, that maximum is:

• $10,600 for self-only coverage
• $21,200 for other than self-only coverage

These 2026 amounts are different from 2025, and they also replaced the earlier 2026 figures that were previously announced.

What this means for you:

• If your plan had been near the top of the allowed maximum, your plan’s out-of-pocket cap may have moved in 2026.
• Even if you have the same insurer, the specific plan design (deductible, copays, coinsurance, and out-of-pocket maximum) can change year to year.
• This cap typically applies to in-network covered essential health benefits. Out-of-network care and non-covered services usually do not count toward the cap.

Medicare Part D (standalone Part D and Medicare Advantage plans with drug coverage)

Medicare prescription drug coverage has its own annual out-of-pocket maximum for covered Part D drugs.

For 2026, the out-of-pocket maximum for Part D covered prescription drugs is $2,100.

This is separate from any medical out-of-pocket cap you may have for hospital and outpatient care. It also differs from 2025, when the out-of-pocket cap for covered Part D drugs was lower.

What this means for you:

• If you take expensive medications, your “worst-case” prescription spending for covered Part D drugs is more predictable for 2026.
• Premiums, non-covered drugs, and some pharmacy charges may not count toward the cap, so it’s still important to confirm what your plan counts.
• If large prescription costs hit early in the year, Medicare also allows a payment option that can help you spread costs across months, depending on your situation and plan rules.

Medigap (Medicare Supplement) Plan K and Plan L

Original Medicare does not have a universal annual out-of-pocket maximum. However, Medigap Plan K and Plan L include annual out-of-pocket limits that reset each year.

For 2026:

• Plan K out-of-pocket limit: $8,000
• Plan L out-of-pocket limit: $4,000

What this means for you:

• If you have Plan K or Plan L, your annual “ceiling” for certain Medicare cost sharing is different in 2026.
• Premiums do not count toward these limits.
• These limits apply specifically to the way Plans K and L are designed (they cover a percentage of certain Medicare cost-sharing amounts until you reach the plan’s out-of-pocket limit, after which the plan pays 100% of covered cost sharing for the rest of the year, per plan rules).

HSA-qualified high-deductible health plans (HDHPs)

If you have an HSA-qualified HDHP, the IRS updates the maximum out-of-pocket limit that a plan can have and still qualify as an HSA-compatible HDHP.

For 2026, an HSA-qualified HDHP must have out-of-pocket expenses (not including premiums) that do not exceed:

• $8,500 for self-only coverage
• $17,000 for family coverage

What this means for you:

• If you have an HSA plan through work or you bought an HSA-qualified plan yourself, your plan’s out-of-pocket maximum may shift to match updated IRS limits.
• Some plans set their out-of-pocket maximum lower than the IRS ceiling, so your personal plan details still matter most.

Medicare Advantage (Part C)

Medicare Advantage plans are required to include an annual maximum out-of-pocket for covered Part A and Part B services, but the exact number can vary by plan and can change each year.

What this means for you:

• Your plan’s maximum out-of-pocket might go up, down, or stay the same for 2026.
• A plan can keep the same premium and still change copays, coinsurance, and the out-of-pocket maximum, so it’s worth reviewing your 2026 documents even if nothing else feels different.

What these 2026 changes could mean for you

Your “worst-case year” may look different

If your out-of-pocket maximum increased, you may be exposed to more cost in a high-need year. If it decreased, you may have more protection, but you still need to watch deductibles, coinsurance, and network rules.

A helpful way to think about it:

• Premium is what you pay to keep coverage.
• Deductible and cost sharing are what you pay as you use care.
• Maximum out-of-pocket is the “stop point” for many covered, in-network costs.

You want these three to make sense together for your health needs and your budget.

Prescription costs may be more predictable, but only if your drugs are covered

A Part D out-of-pocket maximum is most helpful when your medications are on your plan’s formulary and filled according to plan rules (correct pharmacy network, prior authorization when required, and so on).

If you’re managing multiple medications, it can help to check:

• Whether each medication is covered
• Which pharmacy tier applies
• Whether you need prior authorization
• Whether quantity limits apply

Plan comparisons should focus on your personal pattern of care

Two people can have the same diagnosis and very different costs depending on:

• How often you see specialists
• Whether you use out-of-network clinicians
• Whether you need infusions, imaging, procedures, or durable medical equipment
• Whether you use high-cost brand medications

If you are comparing plans, use your last year of care as a “test run” and ask: “What would I have paid under this plan’s deductible, copays, coinsurance, and maximum out-of-pocket?”

How to check whether your plan’s maximum out-of-pocket changed

Step-by-step checklist

• Find the plan document that lists your costs:
  • Employer or Marketplace plans: Summary of Benefits and Coverage (SBC) and full policy
  • Medicare Advantage and Part D: Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
  • Medigap: your Plan K or L materials and the current year’s limit
• Look for the section labeled “out-of-pocket maximum,” “maximum out-of-pocket,” or “annual limitation on cost sharing.”
• Confirm what counts toward the limit:
  • In-network only, or also out-of-network?
  • Medical services only, or also prescription drugs?
  • Does the deductible count?
• If you have more than one coverage type (for example, Medicare plus Medigap, or Medicare plus retiree coverage), confirm how the coverages coordinate.

When it’s worth calling your plan

Consider calling if you are:

• Planning surgery, imaging, infusions, or other high-cost services
• Starting a new specialty medication
• Using out-of-network clinicians
• Helping a parent or partner manage multiple conditions and frequent appointments

A short, clear question often works best: “Can you tell me my 2026 maximum out-of-pocket, what counts toward it, and whether prescriptions have a separate cap?”

Related Understood Care resources

If you want help understanding bills, benefits, or coverage changes, these Understood Care resources can help you get oriented:

• https://understoodcare.com/uc-articles/helping-you-understand-your-benefits
• https://understoodcare.com/uc-articles/struggling-with-medical-bills
• https://understoodcare.com/uc-articles/financial-help
• https://understoodcare.com/care-types/analyze-bills
• https://understoodcare.com/care-types/care-coordination
• https://understoodcare.com/care-types/lower-costs-of-medication

FAQ

• What is the 2026 out-of-pocket maximum for ACA Marketplace plans?
  For 2026, the federal maximum annual limitation on cost sharing is $10,600 (self-only) and $21,200 (other than self-only), though many plans set lower limits.
• Does the out-of-pocket maximum include monthly premiums?
  Usually no. Premiums are generally separate from the out-of-pocket maximum.
• What is the Medicare Part D out-of-pocket maximum in 2026?
  For covered Part D prescription drugs, the out-of-pocket maximum is $2,100 in 2026.
• Is the Medicare Part D out-of-pocket maximum the same as my Medicare Advantage out-of-pocket maximum?
  No. Part D drug spending has its own out-of-pocket maximum. Medicare Advantage plans also have a separate medical maximum out-of-pocket for Part A and Part B services.
• Which Medigap plans have an annual out-of-pocket limit in 2026?
  Medigap Plans K and L have annual out-of-pocket limits. Other Medigap plans generally do not have an annual out-of-pocket maximum in the same way.
• How do I find my plan’s maximum out-of-pocket quickly?
  Check your SBC (employer or Marketplace plans) or your ANOC/EOC (Medicare Advantage or Part D). Look for “maximum out-of-pocket” or “annual limitation on cost sharing.”
• If my out-of-pocket maximum increased for 2026, what can I do?
  Start by confirming what counts toward the maximum, whether you can reduce costs by staying in-network, and whether there are medication savings options available through your plan.

References

• https://www.federalregister.gov/documents/2025/06/25/2025-11606/patient-protection-and-affordable-care-act-marketplace-integrity-and-affordability
• https://www.cms.gov/newsroom/fact-sheets/final-cy-2026-part-d-redesign-program-instructions
• https://www.cms.gov/about-cms/strategy/medicare-prescription-drug-improvements
• https://www.cms.gov/medicare/health-drug-plans/medigap/k-l-out-of-pocket-limits-announcements
• https://www.irs.gov/irb/2025-21_IRB‍