A client's out-of-pocket maximum does not cap a bill from abroad
Three provisions hold together and the result is uncapped exposure. A provider that has not contracted with the plan is out-of-network, no federal payment floor applies outside three narrow situations, and the annual limitation on cost sharing is not required to reach out-of-network care at all.
Published November 7, 2026
9 min read
Information provided is for general reference only and does not constitute medical advice. Consult a qualified healthcare professional before making medical decisions.
A client's out-of-pocket maximum, $10,600 for self-only marketplace coverage in 2026, is not required to count cost sharing for out-of-network care. A foreign provider that has not contracted with the plan is out-of-network, and federal payment floors apply in only three situations, none of them a planned operation. The exposure has no federal ceiling.
Sylk Health. Current as of October 2026.
A companion post on what might pay for treatment abroad established that no general federal rule says whether a plan pays for care obtained outside the United States, and that what federal law delivers here is disclosure rather than substance. This post sets out the mechanism that decides what such a plan does with a foreign bill. Nothing here is legal or tax advice, no carrier or plan is named, and nothing here addresses whether we pay brokers.
The 2026 figures at a glance
The table below gives the figures in this post with their year and source attached.
Figure
2026 amount
Source
Annual limitation on cost sharing, self-only
$10,600
Final rule, 90 FR 27074, June 2025
Annual limitation on cost sharing, other coverage
$21,200
Same
Superseded self-only figure from earlier guidance
$10,150
Superseded by the same rule
Minimum deductible for an HSA-qualifying plan
$1,700 self-only; $3,400 family
Revenue Procedure 2025-19
Maximum out-of-pocket for an HSA-qualifying plan
$8,500 self-only; $17,000 family
Same
The final rule (opens in new tab) states that it is "finalizing a maximum annual limitation on cost sharing of $10,600 for self-only coverage for PY 2026 to supersede the maximum annual limitation on cost sharing of $10,150 ...", so anyone quoting $10,150 is quoting a superseded number. The HSA thresholds (opens in new tab) come from a 2025 revenue procedure, and the eligibility statute behind them contains no geographic condition; our verifier searched the whole statute and found nothing about location.
Why is a foreign provider out-of-network?
Because it has not contracted with the plan, not because of where it is. The surprise-billing definitions (opens in new tab) provide that a "Nonparticipating provider means any physician or other health care provider who does not have a contractual relationship directly or indirectly with a group health plan or group or individual health insurance coverage offered by a health insurance issuer ...". That is what puts a foreign hospital outside the network, and it would apply equally to a hospital down the road that had never signed with the plan.
A separate definition makes a different point. "State means each of the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands." That closed list does not make a foreign provider out-of-network. What it shows is that the framework was not built with foreign providers in contemplation. Conflating the two definitions would invite a correction from anyone who reads the regulations.
Where does a federal payment floor apply?
In three situations, and the list is closed:
Emergency services.
Certain non-emergency services delivered by a nonparticipating provider at a participating facility.
Air ambulance services.
Our verifier read the neighbouring provisions to see whether anything else created a floor, and nothing does. The first situation is the one clients most often have in mind, because an emergency while travelling feels like the case insurance exists for. A complication that becomes an emergency abroad may engage it; the planned operation that preceded it does not, and the emergency rules themselves are built around domestic constructs that a foreign hospital may not fit. Outside those three, a plan is under no federal obligation to pay a nonparticipating provider anything in particular, and a planned operation in another country is outside all three.
What does the out-of-pocket maximum not reach?
Out-of-network care, and balance bills. The cost-sharing regulation (opens in new tab) contains a special rule for network plans: "cost sharing paid by, or on behalf of, an enrollee for benefits provided outside of such network is not required to count toward the annual limitation on cost sharing". The marketplace's own glossary (opens in new tab) lists "Out-of-network care and services" among the things that do not count toward the maximum, along with "Anything you spend for services your plan doesn't cover".
The definition of cost sharing closes the loop, because it expressly excludes balance billing by out-of-network providers. The difference between what a provider charges and what a plan pays is therefore not cost sharing, is not capped, and does not accumulate toward anything. Read the three provisions together and the exposure has no ceiling.
May a plan simply exclude foreign care?
Nothing in federal law addresses it. Six regulatory schemes were searched, and the second reader repeated the exercise with a wider list of terms. Neither found any provision permitting or prohibiting a geographic exclusion, and the essential health benefits requirements say nothing about where care is delivered or who delivers it.
One near miss looks decisive and is not. The nondiscrimination rules (opens in new tab) refer to a "different geographic location", but that provision concerns how an employer may classify groups of employees for plan design, not where a benefit may be delivered. Whether a plan covers care in another country is a question of plan design, answered by the plan document and nothing above it.
What is a client entitled to be told?
Disclosure is where the federal obligations sit, so the timetables are worth carrying. The summary of benefits (opens in new tab) must be provided on application, on renewal and on request, within windows running from seven business days to thirty days depending on the trigger, and sixty days' advance notice is required of a mid-year change to its content. That summary must either summarise coverage provided outside the United States or give an internet address or similar contact information where it can be found. For a plan governed by the federal benefits statute, the plan description is due within 90 days of a person becoming a participant, or within 120 days of the plan becoming subject to the rules, and a material modification must be summarised within 210 days, shortened to 60 days where the change reduces benefits.
Frequently asked questions
Does a marketplace plan's out-of-pocket maximum cap a bill from a hospital abroad?
Not if the hospital is out-of-network, which a foreign hospital without a contract with the plan is. Federal rules provide that cost sharing for out-of-network benefits "is not required to count toward the annual limitation on cost sharing", and balance bills are not cost sharing at all. The 2026 limit of $10,600 self-only therefore does not protect a client from a foreign bill.
Does the No Surprises Act protect a client treated abroad?
Only in its three situations: emergency services, certain non-emergency services at a participating facility, and air ambulance services. A planned operation in another country falls outside all three. The implementing regulation's definition of a State lists 50 states and the domestic territories and nothing else, which shows the framework was not built with foreign providers in mind.
Can a plan exclude care received outside the United States?
Federal law neither permits nor prohibits it in terms. Two readers searched 6 regulatory schemes and found no provision on geographic exclusions, so the answer is in the plan document. The summary of benefits must summarise coverage outside the United States or say where to find it, and a client can request it, with a response due within seven business days.
What the out-of-pocket maximum means for a foreign bill
The out-of-pocket maximum sounds like a maximum, and for a foreign bill it is not one. A client asking whether their plan will cover an operation abroad is asking a plan-document question rather than a regulatory one. What the regulations settle is narrower: if the plan does not cover it, or covers it as out-of-network, no federal floor governs what the provider may charge and nothing caps what the client may owe. Our post on what a licence lets an agent say covers how far that conversation can go.
We publish procedure prices from outside the United States and nothing else. We do not arrange care, assess providers, or advise on cover.
This article is general information about federal regulations and agency guidance. It is not medical, legal, tax or financial advice; consult counsel or a benefits adviser on any individual plan.
Disclosure: Sylk Health supplies procedure-price data and earns a commission from providers on bookings completed through its platform. It would benefit from broader use of externally benchmarked prices for medical procedures, and from any gap between those prices and prices in the United States.
45 CFR 149.30 (opens in new tab), definitions of nonparticipating provider, of State as a closed domestic list, and of cost sharing excluding balance billing by out-of-network providers.
45 CFR 149.110, 149.120 and 149.130, the three situations in which a payment floor applies; neighbouring provisions 149.100, 149.140 and 149.150 read and confirmed to create no further floor.
45 CFR 147.200 (opens in new tab) for summary of benefits timing, and 29 CFR 2520.102-3(l), 2520.104b-2 and 2520.104b-3 for plan description timetables.
Searched and not found, across six regulatory schemes by two readers: any federal provision addressing whether a plan may exclude care obtained outside the United States.
Browse provider-listed prices on medical procedures at accredited international hospitals. No coordinator, no callbacks. Send a consultation request directly.
