Premium

The premium is the amount paid to keep coverage active. It is usually billed monthly. Marketplace financial assistance may reduce the portion an eligible household pays, but the Marketplace makes the final determination.

Deductible

The deductible is the amount you may pay for covered services before the plan begins sharing certain costs. Some services may have copays before the deductible, while other services may require the deductible first. Always check the plan documents.

Copay and coinsurance

A copay is a fixed amount for a covered service, such as an office visit. Coinsurance is a percentage of the plan’s allowed cost. A service can be subject to a copay, coinsurance, the deductible, or a combination depending on the plan.

Out-of-pocket maximum

The out-of-pocket maximum limits what a member pays for covered, in-network care during a plan year. Premiums, non-covered services, and many out-of-network costs generally do not count toward that limit.

Better comparison: consider expected care and a high-use scenario. Compare the premium plus likely cost sharing, not just one number.

Questions to ask

  • Which services are covered before the deductible?
  • Are prescriptions subject to a separate deductible?
  • Which providers and pharmacies are in network?
  • What counts toward the out-of-pocket maximum?