Five words decide what a health plan really costs you. Here they are, with an example.
What you pay every month to have the plan, whether or not you use it. Your premium tax credit, if you qualify, lowers this.
What you pay for covered care each year before the plan starts paying its share. Many plans cover some things before the deductible, such as preventive care, which is free on every plan, and some office visits or prescriptions with a copay.
A copay is a flat amount, for example $30 for a primary care visit. Coinsurance is a percentage: with 20% coinsurance you pay 20% of the bill and the plan pays 80%, usually after the deductible.
The most you pay in a year for covered, in-network care: deductible, copays and coinsurance added together. After you hit it, the plan pays 100% for the rest of the year. For 2027 the federal ceiling is $12,000 for one person and $24,000 for a family; most plans set it lower. Premiums do not count toward it.
The doctors, hospitals and pharmacies the plan has contracts with. Going outside the network can cost much more, or not be covered at all. Always check your doctors before you choose.
Say your plan has a $3,000 deductible, 20% coinsurance and a $7,000 out-of-pocket maximum, and you have a $10,000 hospital bill. You pay the first $3,000, then 20% of the remaining $7,000, which is $1,400. Total: $4,400. If the bill were $40,000 you would stop at $7,000 and the plan would pay the rest.
A copay is a fixed dollar amount for a service. Coinsurance is a percentage of the bill you pay, usually after meeting the deductible.
No. Premiums keep the plan active. The deductible and out-of-pocket maximum count only what you pay for covered care.
The plan pays 100% of covered in-network care for the rest of the plan year.
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