The 2027 Out-of-Pocket Maximum Jumped 13%. Do Not Let Your Plan Design Quietly Follow It.

When a federal limit goes up, the carriers tend to follow it, and a plan that was "at the max" last year quietly becomes a plan with a thousand dollars more exposure for your employees. That is what is happening with the 2027 out-of-pocket maximum, and I want employers to walk into renewal knowing it.

The 2027 numbers

HHS set the 2027 ACA maximum on in-network cost sharing for essential health benefits at $12,000 for self-only coverage and $24,000 for family coverage. For 2026 those figures were $10,600 and $21,200. That is roughly a 13.2% increase, far above medical inflation, and it comes from a change in how HHS calculates the premium adjustment percentage, not from any change in what care costs.

So the ceiling moved for a technical reason. Your plan does not have to move with it.

Two sets of limits, not one

This trips people up every year. The ACA limits above are the outer boundary for any non-grandfathered plan. HSA-qualified high-deductible plans have their own, lower IRS limits: $8,700 self-only and $17,400 family for 2027. If you offer an HDHP alongside a PPO, the two plans are being measured against two different caps. A carrier quoting an HDHP with a $12,000 out-of-pocket max has made an error, and it would disqualify the HSA.

The embedded individual limit

The self-only maximum has to apply to every person on a family plan. In practice, no single family member can be asked to pay more than $12,000 in 2027 even if the family maximum is $24,000. Most carrier plans handle this correctly, but we still see it missed on older self-funded plan documents and on some level-funded designs that were built years ago and never revisited. If you are self-funded, this is a plan-document question, and it is worth a ten-minute check.

What is legal versus what is wise

A $12,000 out-of-pocket max for a single employee is legal. For most of the workforces we serve in Central Florida, it is also unrealistic. A medical event that reaches that number is a financial crisis for an employee earning $45,000, and the plan's protection becomes theoretical.

I am not saying every plan needs a low maximum. I am saying the decision should be yours. When the carrier renewal arrives with the out-of-pocket limit nudged up "to the federal maximum," that is a plan change, and it deserves the same scrutiny as a premium increase. Ask what it saves. Often it is less than you would expect, because very few people hit the max in any given year, and the savings are small while the exposure for the person who does hit it is large.

A short checklist for 2027

Confirm your non-HDHP plans are at or below $12,000 and $24,000. Confirm your HDHP is at or below $8,700 and $17,400 and still meets the $1,750 and $3,500 minimum deductibles. Confirm the embedded individual limit in any family tier. And decide, deliberately, where you want the out-of-pocket maximum to sit for your people.

This is general guidance rather than legal advice. If you want us to review your renewal against these limits before you sign, send it over.