The monthly premium gets all the attention, but it's only part of what you'll pay. Four other numbers decide what care actually costs you.
The definitions
- Premium: what you pay every month to keep the plan, whether or not you use care.
- Deductible: what you pay for covered care before the plan starts sharing costs. Many plans cover preventive care and some copay services before the deductible.
- Copay: a flat amount for a service, such as $30 for a doctor visit.
- Coinsurance: your percentage of the cost after the deductible, such as 20%.
- Out-of-pocket maximum: the most you'll pay in a plan year for covered, in-network care. After that, the plan pays 100% of covered in-network services. Premiums don't count toward it.
A simple example
This is an illustration only. Suppose a plan has a $3,000 deductible, 20% coinsurance and a $7,000 out-of-pocket maximum, and you have a $20,000 covered in-network hospital bill:
- You pay the first $3,000 (the deductible).
- Of the remaining $17,000, you pay 20%, which would be $3,400.
- Your total would be $6,400, under the $7,000 maximum, so the plan pays the rest.
Had the bill been larger, your share would stop at $7,000 for the year.
2027 limit worth knowing
- ACA-compliant plans: in-network out-of-pocket maximum of no more than $12,000 for an individual and $24,000 for a family in 2027 (up from $10,600 and $21,200 in 2026).
How to estimate your real yearly cost
For each plan, add up two scenarios: a quiet year (premiums plus a few visits and prescriptions) and a bad year (premiums plus the out-of-pocket maximum). The plan with the lowest premium isn't always cheapest in either scenario.
We run both scenarios for every plan we show you. See individual health insurance and family health insurance.
Sources
General information only, not tax, legal or medical advice. Plan availability, benefits, networks and pricing vary by carrier, state, county and eligibility. Stratton Advisory Group is an independent agency and is not affiliated with any insurance carrier or government agency.