Skip to main content

An official website of the United States government

Here's how you know

How to pick a health insurance plan

Your total costs for health care: Premium, deductible & out-of-pocket costs

When picking a Marketplace health plan, it's important to compare your estimated total yearly costs for each plan - not just the premium. The costs when you get care can have a big impact on your budget. Total yearly costs include:
  • Monthly premium x 12 months: The amount you pay to your plan each month to have health insurance.
  • Deductibles: How much you'll spend for certain covered health services and prescription drugs before your plan pays anything, except free preventive services. (For example, your plan may charge for an office visit, but you won't pay extra for the preventive service that's part of that visit.)
  • Copayments and coinsurance: The amounts you pay your health care provider each time you get care, like $20 for a doctor visit or 30% of hospital charges.
  • Out-of-pocket maximum: The most you'll spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.

Example of how you and your plan share costs when you get care:

Jane’s Marketplace plan coverage starts on January 1. The plan’s deductible is $1,500, the coinsurance is 20%, and the plan’s out-of-pocket maximum is $5,000. (Jane’s plan has a different deductible, coinsurance, and out-of-pocket maximum for prescription drugs. This example only shows costs for health services.)
  • Deductible: When Jane’s coverage starts each year, Jane must pay her plan’s deductible for certain health services before the plan starts to pay. In February, Jane hasn’t reached the deductible yet. Jane pays all costs for most covered health services until she pays $1,500. 
    • Office visit cost: $125
    • Jane pays: $125 
    • Plan pays: $0 
Deductible: A weighed scale leaning more towards the customer, Jane, who is paying 100% and less towards her plan who is paying zero.Deductible: A weighed scale leaning more towards the customer, Jane, who is paying 100% and less towards her plan who is paying zero.
  • Coinsurance: In May, Jane reaches her plan’s deductible. Now, Jane’s plan will pay some of the costs, and Jane will pay the coinsurance or copayment amount for each covered health service. Jane will continue to pay her part until she reaches the plan’s out-of-pocket maximum.
    • Office visit: $125
    • Jane pays: $25 (Jane’s coinsurance is 20%. $125 x 20% = $25.)
    • Plan pays: $100 (Plan pays 80%. $125 x 80% = $100.)
Coinsurance: A weighed scale leaning less towards the customer, Jane, who is paying 20% and leaning more towards her plan who is paying 80%.Coinsurance: A weighed scale leaning less towards the customer, Jane, who is paying 20% and leaning more towards her plan who is paying 80%.
  • Out-of-pocket maximum: Jane got services throughout the year, and by October Jane had paid $5,000 in total for covered health services (her plan’s out-of-pocket maximum). Now, Jane’s plan will pay all costs for covered health services through the end of the coverage period (usually December 31).
    • Office visit: $125
    • Jane pays: $0
    • Plan pays: $125
Out-of-pocket limit: A weighed scale leaning less towards the customer, Jane, who is paying zero and more towards her plan who is paying 100%.Out-of-pocket limit: A weighed scale leaning less towards the customer, Jane, who is paying zero and more towards her plan who is paying 100%.

Compare estimated total costs for plans

To find a plan that meets your needs and budget, consider:
Your health care needs when shopping for coverage
Determine the types and amount of health services and prescription drugs your household will likely use for the year. Deductibles, copayments, and coinsurance can add a lot to your total yearly costs - sometimes more than a plan's premium. 
When you compare plans, you can get a more accurate estimate of your total yearly costs for each plan, based on the level of care you think your household will use for the year. To preview plans and prices:
  1. Select "Add yearly cost" on any of the plans listed.
  2. Pick the level of care you expect to use this year— low, medium, or high.
  3. Select "Save and continue" to get your estimated total yearly costs for each plan listed.
Your actual costs will vary based on the services you use. This estimate can help you compare each plan's total impact on your household budget.
Preview plans & prices

Compare plans marked with "easy pricing"

These plans:
  • Have the same out-of-pocket costs and care before deductibles for some services.

What services count for day 1 coverage?

In an “easy pricing” plan, you’ll only pay a copayment for:
  • Primary care 
  • Specialist care
  • Urgent care
  • Outpatient mental health
  • Physical, speech, and occupational therapy
  • Generic and most preferred prescription drugs
  • Are easier to compare because they have the same deductibles, copayments/coinsurance, and out-of-pocket maximums within their health plan category.
You can choose to view only easy pricing plans. When comparing plans:
  1. Select “Add filters.”
  2. Under “Health plan categories,” pick Bronze, Silver, Gold, or Platinum.
  3. Under the plan category you pick, check the box “with easy pricing.”
 

 

Back to top