Healthcare & MedicalStop-Loss Ceiling

Out-of-Pocket Maximum Calculator

Track how close you are to reaching your annual Out-of-Pocket Maximum, separating eligible in-network cost sharing from excluded premiums and non-covered services.

Plan OOP Maximum Limit ($)

Deductible Paid So Far ($)

Copays Paid So Far ($)

Coinsurance Paid So Far ($)

Anticipated Upcoming Procedure Claim ($)

Insurance Cost Summary

Out-of-Pocket Maximum Tracking Formula

Remaining Until OOPM = Statutory OOPM Limit - (Deductible Paid + In-Network Copays + Coinsurance Paid)

Statutory Limit: The maximum annual limit established under the Affordable Care Act (ACA).
Eligible Cost-Sharing: Deductibles, copays, and coinsurance for in-network essential health benefits.
Exclusions: Monthly premiums, balance-billed out-of-network fees, and non-covered elective care.

Step-by-Step Worked Example

Scenario: Policyholder with a $7,500 individual Out-of-Pocket Maximum who has paid $2,000 in deductibles, $450 in copays, $1,800 in coinsurance, $900 in non-covered elective care, and $2,400 in insurance premiums.

Calculation Steps:

Qualified Cost-Sharing = $2,000 + $450 + $1,800 = $4,250.
Remaining Until OOPM Met = $7,500 - $4,250 = $3,250.
Total Cash Outflow = $4,250 + $900 (non-covered) + $2,400 (premiums) = $7,550.

Result: The patient has satisfied $4,250 of their $7,500 OOPM limit ($3,250 remaining). While true cash outflow is $7,550, premiums and elective care do not count toward the protection cap.

How to Use This Calculator

1Find your in-network Out-of-Pocket Maximum limit on your insurance card.
2Input the deductible, copayment, and coinsurance amounts paid to date.
3Add any non-covered expenses or premiums to audit total medical cash flow.

Assumptions & Limitations

Applies strictly to in-network essential healthcare services.
Separate out-of-network maximums may apply if your plan offers out-of-network benefits (PPO).

Frequently Asked Questions

Does my family have one shared Out-of-Pocket Maximum?

Yes, but under ACA rules, individual family members typically have an embedded individual maximum that protects them even before the full family maximum is reached.

What is the federal Out-of-Pocket Maximum limit?

The federal government establishes annual maximum caps for ACA-compliant plans (e.g. $9,450 for individuals and $18,900 for families in recent plan years).

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