The U.S. Department of Health and Human Services released the 2027 Affordable Care Act (ACA) maximum cost-sharing limits: $12,000 for self-only coverage and $24,000 for family coverage. This is an increase of about 13.2% over 2026. Employers should review their plan designs annually to ensure they remain within these ACA limits.
Out-of-Pocket Maximum
The ACA requires most health plans to follow annual limits on total enrollee cost sharing for essential health benefits (EHBs). These limits, known as out-of-pocket maximums (OOPM), apply to all non-grandfathered health plans, including self-insured, level-funded, and fully insured plans of any size.
Under the ACA, essential health benefits (EHBs) must mirror the scope of a typical employer plan and span 10 categories, such as emergency services, hospitalization, prescription drugs, pediatric services, outpatient care, and maternity and newborn care. Because ACA cost-sharing limits apply only to EHBs, plans are not required to apply the annual out-of-pocket maximum to non-EHB benefits.
Once the annual OOPM is met, the enrollee is no longer responsible for cost sharing on EHBs for the rest of the year. All out-of-pocket costs for EHBs, such as deductibles, copayments, coinsurance, and similar charges, must count toward this limit, but premiums and noncovered services do not. For plans with provider networks, expenses for out-of-network benefits are not required to count toward the OOPM.
Embedded OOPM
Under the ACA, the self-only cost-sharing limit applies to each covered individual, even undern family coverage. This means health plans must either: (1) set the family maximum OOPM at or below the self-only limit ($12,000 for 2027 plan years), or (2) include an embedded individual OOPM within family coverage that does not exceed the self-only limit.
High Deductible Health Plan
High deductible health plans (HDHPs) compatible with health savings accounts must meet specific IRS limits on out-of-pocket costs. While the 2027 limits are not yet available, for 2026 plan years the maximum out-of-pocket limit is $8,500 for self-only coverage and $17,000 for family coverage.
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