The short version
- What a plan really costs you in a year is your premiums plus what you pay when you use care.
- The out-of-pocket maximum is the most you'd pay for covered in-network care in a year, not counting premiums.
- The network, and whether your prescriptions are covered, can matter as much as the price.
The five numbers
Premium
What you pay every month to keep the plan, whether or not you use it.
Deductible
What you pay for covered care each year before the plan starts sharing the cost. Many plans cover some services before you've met the deductible, such as certain doctor visits or generic drugs, so check the details.
Copay
A set fee for a particular service, such as a doctor's visit or a prescription.
Coinsurance
Your percentage share of the bill after you've met the deductible. With 20% coinsurance, you pay 20% and the plan pays 80%.
Out-of-pocket maximum
The most you'll pay in a plan year for covered, in-network care. Once you reach it, the plan pays 100% of covered in-network costs for the rest of the year. Your premiums don't count towards it.
How they work together
Imagine a plan with a $2,000 deductible, 20% coinsurance and a $6,000 out-of-pocket maximum. You have a hospital stay that comes to $20,000 at the insurer's negotiated rate.
- You pay the first $2,000, which is your deductible.
- Of the remaining $18,000, you pay 20% coinsurance: $3,600.
- That brings you to $5,600, still under your $6,000 maximum, and the plan pays the other $14,400.
Add a year's premiums on top and you have the real worst-case cost of that plan. That's the number worth comparing between plans.
Example only
These figures are made up to show how the parts fit together. Real deductibles, limits and prices vary by plan and by state.
The metal levels
Marketplace plans are grouped into metal levels by how costs are split on average, not by the quality of care:
- Bronze. The lowest premiums and the highest costs when you use care. The plan pays about 60% of costs on average.
- Silver. About 70%. If your income qualifies, Silver plans can also come with cost-sharing reductions that lower your deductible and copays.
- Gold. About 80%. Higher premiums, lower costs when you use care.
- Platinum. About 90%, where it's offered.
Networks: HMO, PPO and EPO
The network is the list of doctors and hospitals the plan works with. The type of plan tells you how strict it is:
- HMO. You usually need to use in-network providers, and you may need a referral to see a specialist.
- PPO. You can go out of network, though you'll pay more when you do.
- EPO. Usually no referrals, but no coverage out of network except in emergencies.
Before you choose, check that your doctors are in the network and that your regular prescriptions are on the plan's drug list, called its formulary.
Preventive care
Plans that meet Affordable Care Act rules cover a set of preventive services, including many screenings and vaccines, at no cost to you when you use an in-network provider, even before you've met your deductible.
How I can help
Send me your doctors, your prescriptions and what you'd comfortably spend each month. I'll work out the worst-case yearly cost of the plans that fit, not just the monthly premium, so you can compare them fairly.
See the states where I'm licensed
This article is general information, not advice about your own situation. Plan designs, networks and prices vary by insurer and by state, and can change from year to year.
