When choosing a plan, it’s a good idea to think about your total health care costs, not just the bill (the “premium”) you pay to your insurance company every month.
Other amounts, sometimes called “out-of-pocket” costs, have a big impact on your total spending on health care – sometimes more than the premium itself.
Beyond your monthly premium: Deductible and out-of-pocket costs
- Deductible: How much you have to spend for covered health services before your insurance company pays anything (except free preventive services)
- Copayments and coinsurance: Payments you make each time you get a medical service after reaching your deductible
- Out-of-pocket maximum: The most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.
How to estimate your yearly total costs of care
In order to pick a plan based on your total costs of care, you’ll need to estimate the medical services you’ll use for the year ahead. Of course it’s impossible to predict the exact amount. So think about how much care you usually use, or are likely to use.
- Before you compare plans when you’re logged in to HealthCare.gov or preview plans and prices before you log in, you can choose each family member’s expected medical use as low, medium, or high.
- When you view plans, you’ll see an estimate of your total costs — including monthly premiums and all out-of-pocket costs — based on your household’s expected use of care.
- Your actual expenses will vary, but the estimate is useful for comparing plans’ total impact on your household budget.
Total costs & “metal” categories
When you compare plans in the Marketplace, the plans appear in 4 “metal” categories: Bronze, Silver, Gold, and Platinum. The categories are based on how you and the health plan share the total costs of your care.
Generally speaking, categories with higher premiums (Gold, Platinum) pay more of your total costs of health care. Categories with lower premiums (Bronze, Silver) pay less of your total costs. (But see the exception about Silver plans below.)
So how do you find a category that works for you?
- If you don’t expect to use regular medical services and don’t take regular prescriptions: You may want a Bronze plan. These plans can have very low monthly premiums, but have high deductibles and pay less of your costs when you need care.
- If you qualify for "cost-sharing reductions" (CSRs): Silver plans may offer good value. If you qualify, your deductible will be lower and you’ll pay less each time you get care. But you get these extra savings only if you enroll in Silver. If you don’t qualify for CSRs, compare premiums and out-of-pocket costs of Silver and Gold prices to find your right plan. See if your income estimate falls in the range for cost-sharing reductions.
- If you expect a lot of doctor visits or need regular prescriptions: You may want a Gold plan or Platinum plan. These plans generally have higher monthly premiums but pay more of your costs when you need care.