HHS Revises Out-of-Pocket Maximum Limits for 2026

The Department of Health and Human Services (“HHS”) released final regulations on the Affordable Care Act (“ACA”) Marketplace Integrity and Affordability. While the regulations generally affect Marketplace Coverage, it did include a revision to the out-of-pocket maximum limits for plan years that begin on or after January 1, 2026. This revision is due to an updated methodology to better align with premium trends. The revised limits are as follows:

• $10,600 for self-only coverage (revised from $10,150)
• $21,200 for coverage other than self-only (revised from $20,300).

It is important to note that the out-of-pocket maximum limits for non-grandfathered group medical plans are different (and generally higher) than the out-of-pocket maximum limits required for high-deductible health plans (“HDHPs”) that are compatible with health savings account (“HSA”) eligibility. For 2026, the out-of-pocket maximum limits for HSA-compatible HDHPs are $8,500 (up from $8,300 for 2025) for self-only coverage and $17,000 (up from $16,600 for 2025) for coverage other than self-only.

In addition, the rule finalized that carriers subject to essential health benefit requirements (“EHBs”) (generally non-grandfathered individual and small market group health plans) may not cover specified sex-trait modification procedures as an EHB. This policy will not prohibit carriers subject to EHB requirements from voluntarily covering specified sex-trait modification procedures, nor will it prohibit states from requiring coverage of such services, subject to the rules related to state-mandated benefits.

Employer Action

• Ensure out-of-pocket maximum limits for 2026 do not exceed the revised maximums.