What is the out of pocket maximum for Anthem policies?
Short answer
Insurance question
The out-of-pocket maximum (OOPM) is the most you pay for covered services in a plan year before your Anthem plan covers 100% of costs. The exact dollar limit varies by plan type and tier — federal law sets annual caps for ACA marketplace plans, while Medicare Advantage and employer plans have their own federally-capped limits. Check your specific plan's Summary of Benefits for your actual number.
This is an independent research summary, not official coverage information. Your plan is the final word.
Key facts
Federal law caps ACA marketplace plan OOPMs annually; the 2026 limit is $9,200 (self-only) / $18,400 (family).
Premiums do not count toward the out-of-pocket maximum under any ACA-compliant health plan.
Once the OOPM is reached, the plan pays 100% of covered in-network costs for the remainder of the plan year.
HealthCare.gov — Out-of-pocket maximum/limit (annual limitation on cost sharing).
Here's the nuance
A one-liner rarely tells the whole story. This is the honest detail behind the short answer above.
The out-of-pocket maximum is a financial protection limit built into all major medical plans. Once you have paid enough in deductibles, copays, and coinsurance over a plan year to reach your OOPM, your Anthem plan covers 100% of in-network covered costs for the rest of that year. This means even with a serious illness or major surgery, your annual exposure for in-network covered care is capped.
For ACA marketplace plans (individual and family Anthem plans sold through HealthCare.gov or state exchanges), the federal government sets annual limits on how high an OOPM can be — these limits are updated each year. For 2026, the federal maximum for marketplace plans is $9,200 for self-only coverage and $18,400 for family coverage. Many Anthem plans set their OOPMs below the federal maximum, so the actual limit on your plan could be lower. Review your plan's Summary of Benefits and Coverage to see the exact figure.
For Anthem Medicare Advantage plans, there is a separate federally-set OOPM limit for in-network services. Medicare Advantage plans can set OOPMs below the federal cap; some plans set lower OOPMs as a competitive benefit. MA plans may also have a separate (higher) combined in-network-plus-out-of-network OOPM. Your plan's Evidence of Coverage document will show both figures.
For employer-sponsored Anthem plans, OOPM limits are also subject to federal rules, but employers have some flexibility in plan design. Your plan's Summary of Benefits and Coverage or HR department can confirm your specific OOPM. A few important rules that apply across all plan types: premiums (your monthly payment) never count toward the OOPM; out-of-network costs may have a separate, higher OOPM or may not count at all toward the in-network limit; and costs for services not covered by your plan (non-covered services) do not count toward the OOPM.
The key points
The handful of things that decide the answer — skim these if you only read one section.
Once you hit the OOPM, Anthem pays 100% of covered in-network costs
All qualifying in-network cost-sharing — deductibles, copays, coinsurance — accumulates toward the OOPM. After you reach it, covered in-network services cost you nothing for the rest of the plan year.
Premiums never count toward the out-of-pocket maximum
Your monthly premium payment is not cost-sharing for a specific service, so it does not count toward the OOPM under any Anthem plan — or any health plan. This is a federal rule under the ACA.
Out-of-network costs have separate rules
Out-of-network deductibles and cost-sharing may accumulate toward a separate, higher OOPM — or may not count toward the in-network OOPM at all. Anthem HMO plans generally have no out-of-network OOPM because out-of-network non-emergency care is not covered.
Non-covered services do not count toward the OOPM
If a service is not covered under your Anthem plan, whatever you pay for it does not count toward your OOPM. Only cost-sharing for covered services accumulates toward the cap.
Find your exact OOPM in your Summary of Benefits and Coverage
Anthem's OOPM varies across plan tiers (Bronze, Silver, Gold, Platinum), plan types (HMO, PPO, EPO), and market segments. The Summary of Benefits and Coverage document for your specific plan shows the exact in-network and combined OOPM. Access it via the Anthem member portal or call member services.
Confirm before you rely on this
Coverage varies by plan — this is not official
Coverage rules, benefit tiers, and medical-necessity criteria change often and differ by plan type, state, employer, and your specific policy. This page is a general, independent research summary — it is not official information from any insurer, not a benefits determination, and not financial or insurance advice.
Verify your exact coverage by calling the member number on your insurance card or checking your plan documents before you rely on any answer here.
Frequently Asked Questions
Yes — under ACA rules, amounts you pay toward your deductible count as cost-sharing and accumulate toward your OOPM. So do copays and coinsurance for covered in-network services. Once the combined total of deductible + copays + coinsurance reaches the OOPM, your Anthem plan covers 100% of covered in-network care for the rest of the plan year. This integration is required for ACA marketplace plans and is standard for most employer plans.
Anthem Medicare Advantage plans have a federally-set maximum OOPM for in-network services that is updated each year by CMS. The actual OOPM on your specific Anthem MA plan may be lower than the federal cap — some plans set lower limits as a competitive benefit. Your plan's Evidence of Coverage document under 'Costs for Covered Services' will show both the in-network OOPM and any combined (in-network plus out-of-network) OOPM. Call Anthem member services or review your plan documents for the exact figures.
Yes. The out-of-pocket maximum resets at the start of each plan year (usually January 1 for calendar-year plans). Any cost-sharing you accumulate during the current plan year does not carry over to the next year. If your plan year is not January through December, the reset date will be the start of your plan year — check your plan documents for the specific dates.
Yes — many Anthem PPO plans have a separate, higher out-of-pocket maximum for out-of-network services. In some plans, out-of-network cost-sharing accumulates separately and never counts toward the in-network OOPM. In other designs, both accrue toward a combined OOPM. Anthem HMO plans typically do not cover out-of-network non-emergency services at all, so there is no out-of-network OOPM. Check your Summary of Benefits and Coverage for how your specific plan handles out-of-network cost accumulation.
Log in to the Anthem member portal or mobile app — your year-to-date deductible and out-of-pocket accumulator are updated as claims are processed. The Explanation of Benefits (EOB) you receive after each covered service also shows running totals. If you have a family plan, the portal will typically show both individual and family accumulators. Tracking your OOPM progress helps with financial planning, especially if you expect significant healthcare costs during the year.
Reviewed by
Curex Editorial TeamReviewed for accuracy
Last reviewed July 2026
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Read moreYour plan has the final say
The surest way to know what's covered is to ask the source. Call the member number on your insurance card or sign in to your plan portal, and have the service or medication name ready — a quick call beats guessing.
This page is independent research, not a benefits determination — your insurer's answer is the one that counts.
This content is for general informational purposes only. It is not official coverage information, a benefits determination, or financial or insurance advice. Coverage rules, benefit tiers, and medical-necessity criteria change often and vary by plan, state, and effective date — always verify your specific benefits directly with your insurer before making any decision.
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