On January 29, 2026, the U.S. Department of Health and Human Services (HHS) officially released the maximum cost-sharing limits for the 2027 plan year. These figures represent a significant 13.2% increase over the 2026 limits, marking a substantial shift in potential out-of-pocket expenses for plan participants.
2027 Maximum Out-of-Pocket Limits
For 2027, the maximum annual limitation on cost-sharing is:
- Self-Only Coverage: $12,000 (Up from $10,600 in 2026)
- Family Coverage: $24,000 (Up from $21,200 in 2026)
Employers must review their current plan designs to ensure they remain compliant with these updated Affordable Care Act (ACA) mandates.
Understanding the Out-of-Pocket Maximum (OOPM)
The ACA requires most health plans to set an annual cap on total enrollee cost-sharing for Essential Health Benefits (EHBs). This limit is commonly known as the Out-of-Pocket Maximum (OOPM).
Scope of Coverage:
- Applicability: These limits apply to all non-grandfathered health plans, including self-insured, level-funded, and fully insured plans of all sizes.
- Included Costs: Deductibles, copayments, and coinsurance all count toward the limit. Premiums and spending for non-covered services are excluded.
- Essential Health Benefits: Limits apply to the 10 EHB categories, such as emergency services, hospitalization, prescription drugs, and maternity care. Plans are not required to apply the OOPM to non-EHB services.
- Network Status: Plans generally do not have to count out-of-network expenses toward the ACA’s cost-sharing limit.
The “Embedded” Individual Limit
Even within a family plan, the ACA’s self-only cost-sharing limit applies to each individual. This means that if a family plan has a total OOPM higher than the self-only limit ($12,000 for 2027), the plan must include an “embedded” individual OOPM.
Once any single individual in a family reaches the $12,000 threshold, the plan must cover 100% of their qualified expenses for the rest of the year, even if the total family limit has not yet been met.
HSA-Compatible High Deductible Health Plans (HDHPs)
It is important to note that HDHPs compatible with Health Savings Accounts (HSAs) are subject to lower out-of-pocket limits set by the IRS.
While the 2027 HDHP limits have not yet been released, for comparison, the 2026 HDHP limits are capped at $8,500 for self-only and $17,000 for family coverage. Employers with HSA-qualified plans should watch for separate IRS guidance later this year.
Next Steps for Employers:
- Audit 2027 plan designs for compliance with the $12,000/$24,000 thresholds.
- Ensure payroll and benefits systems are updated to handle the embedded individual maximums.
- Consult with your benefits advisor to prepare for the upcoming open enrollment cycle.
