Bills · 2026
Family Out-of-Pocket Maximum Calculator
For non-grandfathered family coverage subject to the federal rule, an individual reference can apply before the family maximum is reached. Model the accumulator, then verify plan status, covered services, network treatment, and the EOB.
Common questions
What is the embedded individual maximum?
For non-grandfathered family coverage subject to the federal rule, one person’s cost sharing for covered, in-network essential health benefits cannot exceed the applicable self-only annual limit. Plan status, covered services, network status, and accumulator records still must be verified.
What should I do if the modeled cap and EOB differ?
Ask the plan to identify the accumulator, covered services, network treatment, and plan provision used. The calculator does not establish that an amount is an overcharge.
Does this apply to my plan?
The federal embedded individual rule applies to non-grandfathered group health plans, including applicable self-funded plans, and individual coverage. Confirm grandfathered status and the controlling plan documents before relying on the reference.