The most an Affordable Care Act marketplace plan can require an individual to pay out of pocket in 2027 is rising to $12,000, up from $10,600 this year, while a separate wave of premium increases is landing on top of it. The federal government set both figures using a formula built into the ACA itself, but the premium jump has a more specific cause: the enhanced subsidies that lowered monthly costs for millions of marketplace enrollees expired at the end of 2025 and have not been renewed.
How the New Out-of-Pocket Ceiling Compares to 2026
According to the federal government’s own glossary of marketplace terms, the out-of-pocket limit for an ACA-compliant plan is no more than $10,600 for an individual in 2026, and no more than $12,000 in 2027 — a $1,400 increase for a single person, or $2,800 for a family plan at the family limit. That ceiling covers deductibles, copays, and coinsurance for in-network, covered services, though it excludes monthly premiums and any cost incurred outside a plan’s network.
The limit applies to all non-grandfathered individual and group health plans, not just marketplace policies, which means the increase reaches well beyond people who buy coverage through healthcare.gov or a state exchange. Many employer and marketplace plans set out-of-pocket caps below the federal maximum, but any plan is free to raise its own limit up to that new $12,000 ceiling for 2027 without violating federal rules. Combined, non-grandfathered individual and group coverage reaches more than half the country, so a change to the federal ceiling has a reach far broader than the relatively small share of the population that buys coverage directly through a marketplace.
Coverage of the 2027 enrollment season noted that the Department of Health and Human Services set the new maximum using the same statutory formula it applies every year, separate from the political fight over subsidies. A court decision in July also blocked a broader change that would have let some low-premium Bronze plans push their own limits even higher, up to $15,600, meaning $12,000 remains the ceiling most marketplace shoppers will actually see for 2027.
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Why Premiums Are Climbing at the Same Time
The out-of-pocket ceiling is not the only number moving. Analysis of insurer rate filings found a median proposed premium increase of about 15 percent for 2027, the second straight year of double-digit hikes after last year’s finalized increase of roughly 20 percent. Insurers point to rising medical costs and general inflation as the leading drivers, but they also cite a factor unique to the individual market.
That unique factor is the expiration of the enhanced premium tax credits that had lowered monthly payments for most marketplace enrollees since 2021. When those credits lapsed at the end of 2025, healthier and younger enrollees were the most likely to drop coverage rather than pay full price, leaving a smaller, sicker pool of remaining policyholders behind. Insurers are now pricing 2027 plans against that thinner, costlier risk pool, which pushes rates higher independent of any change in medical costs.
For a marketplace shopper who does not qualify for a subsidy, the combined effect is a plan that costs more every month and protects less once a serious medical event happens. A household that was insulated from previous premium increases by a generous subsidy may see that protection shrink for 2027 even if income has not changed, simply because the subsidy formula itself became less generous when the enhanced credits expired.
Preparing for This Fall’s Marketplace Enrollment
Open enrollment for 2027 marketplace coverage begins November 1 in most states, and insurers are both entering and exiting markets in more than 20 states this year, which means a plan that fit a household’s budget in 2026 may not exist under the same terms for 2027. Letting a marketplace plan auto-renew is riskier this year than in a typical year, since the algorithm that picks a replacement plan does not account for a household’s actual prescriptions or preferred doctors.
Checking the renewal notice for both the new premium and the new out-of-pocket maximum, rather than assuming the plan looks the same as last year, is the only way to know whether a household is now exposed to $1,400 more in potential annual costs. Shoppers who lost a subsidy or saw it shrink should also compare plans across metal tiers, since a Silver or Gold plan’s higher premium can sometimes cost less overall than a Bronze plan once the new out-of-pocket ceiling is factored in.
The $12,000 ceiling and the double-digit premium increases are separate numbers with separate causes — one set by a fixed statutory formula, the other driven by a subsidy cliff working its way through the insurance market — but they land on marketplace households in the same enrollment season. Reviewing both figures before December, rather than after a January bill arrives, is what determines whether the change is a manageable adjustment or an unpleasant surprise.
This article was produced with the assistance of AI and reviewed by The Money Overview editorial team before publication.
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