The U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) have released the 2027 annual limits on cost-sharing under the Affordable Care Act (ACA). These limits apply to all non-grandfathered health plans, including fully insured and self-insured group health plans.
Under the ACA, health plans must cap the total amount an enrollee pays out of pocket each year for essential health benefits (EHBs). Once a participant reaches the annual maximum, the plan must pay 100% of covered in-network essential health benefit costs for the remainder of the plan year.
2027 Out-of-Pocket Maximums
For plan years beginning in 2027, the maximum annual limits on cost-sharing will be:
- $12,000 for self-only coverage
- $24,000 for coverage other than self-only (e.g., family coverage)
By comparison, the 2026 limits are $10,600 for self-only coverage and $21,200 for other than self-only coverage. The 2027 increase represents approximately a 13.2% year-over-year increase, reflecting continued growth in overall healthcare costs.
What Counts Toward the Limit
Cost-sharing generally includes:
- Deductibles
- Coinsurance
- Copayments
- Other required out-of-pocket expenditures for qualified medical expenses related to essential health benefits
Premiums, balance-billed amounts from out-of-network providers (beyond allowed amounts), and non-covered services do not count toward the annual limit.
Employer Considerations
Employers sponsoring non-grandfathered group health plans should review plan designs for 2027 to ensure compliance with the updated limits. While plans may set lower out-of-pocket maximums, they may not exceed the federally established thresholds.
Given the significant increase for 2027, employers may also want to evaluate contribution strategies, employee communications, and overall plan affordability to ensure employees understand how these changes may impact their out-of-pocket exposure.