Individual and Family Plan Out-of-Pocket Costs
When choosing a health plan, it's important to consider all healthcare costs, not only the plan's monthly premium.
These additional expenses, known as out-of-pocket costs, can significantly affect your total healthcare spending. In some cases, your out-of-pocket costs may exceed what you pay in monthly premiums.
Out-of-Pocket Costs
Deductible
The amount you pay for covered healthcare services and prescriptions before your insurance carrier begins paying. After you meet the deductible, you typically pay a copay or coinsurance for covered services, and the insurance carrier pays the remaining covered costs.
Family plans often include both individual and family deductibles. The individual deductible applies to each covered family member, while the family deductible applies to the family as a whole. Amounts applied toward each family member's individual deductible also count toward the family deductible.
Copay
A fixed amount you pay for a covered healthcare service, such as $20 for a doctor visit. The amount is set by your health plan.
Coinsurance
The portion of covered healthcare costs you pay after meeting your deductible. It is usually expressed as a percentage of the cost, such as 20%.
Maximum Out-of-Pocket
The maximum amount you pay for covered healthcare services during a plan year. This limit typically includes deductibles, copays, and coinsurance. Once you reach your out-of-pocket maximum, the insurance carrier pays 100% of covered services for the remainder of the plan year.
Estimating Your Total Yearly Care Costs
When estimating your total yearly healthcare costs, consider how much care you typically use or expect to use based on previous years. While it's impossible to predict your exact expenses, reviewing your past healthcare usage can help you make an informed estimate for the coming year.
Our licensed benefit advisors can help you compare plans and choose one that fits your needs, expected healthcare usage, and budget.
Consider getting a Protection plan to help offset out-of-pocket costs.
Total Costs and Metal Categories
Plans offered through the Health Insurance Marketplace are categorized into four metal tiers: Bronze, Silver, Gold, and Platinum. These tiers reflect how you and the health plan share the cost of covered healthcare services.
Consider the following when determining the category that works for you:
If you don't expect to use healthcare services regularly, a Bronze plan may be a good option. These plans typically have lower monthly premiums. However, you may pay more out of pocket when you need care, including higher deductibles and maximum out-of-pocket costs than plans in higher metal tiers.
If you meet certain income requirements, and you enroll in a Silver plan, you may be eligible for cost-sharing reductions. These reductions can lower your deductible and reduce the amount you pay when you receive care.
If you qualify for a Premium Tax Credit (PTC), you can use it towards a plan premium in any metal tier.
If you expect to visit the doctor frequently or take prescription drugs regularly, a Gold or Platinum plan may be a better fit. These plans generally pay more when you receive care. However, they typically have higher monthly premiums.
Finding Costs for Healthcare Services
To learn about a plan’s coverage and costs, review the carrier’s Summary of Benefits Coverage (SBC). For instructions about the SBC and how to view it, see Reviewing an Individual and Family Plan’s Coverage and Costs.