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Learn how deductibles and out-of-pocket costs affect your total costs of care:


When choosing a health insurance 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.


Here is an overview of the important things to look for when shopping for health insurance: 

  • Deductible: How much you have to spend for covered health services before your insurance company pays anything (except 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.
Ofcourse it’s impossible to predict the exact amount. So think about how much care you usually use, or are likely to use.

Total costs & “metal” categories

When you compare health insurance plans, 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 extra savings on out-of-pocket costs OR want more of your costs covered: Silver plans probably offer the best value. If you qualify for extra savings ("cost-sharing reductions") 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 a Silver plan. This can save you hundreds or even thousands of dollars a year if you use a lot of care. Even if you don’t qualify for extra savings, Silver plans offer good value — moderate premiums and deductibles, and better coverage of your out-of-pocket costs than a Bronze or Catastrophic plan provide.


If you expect many 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.

What is a Deductible?


The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. 

       *Please note NOT ALL procedures are subject to the deductible, so check your summary of benefits. 
         Many plans pay for certain services, like a checkup or disease management programs, before you've met your deductible. 

  • After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
  • Some plans have separate deductibles for certain services, like prescription drugs.
  • Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members
  • Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.

3 things to know before you pick a health insurance plan

Choosing a health insurance plan is not an easy task. Knowing just a few things before you compare plans can make it easier to compare apples to apples and select the right health insurance plan for you and/or your family: 


  • The 4 “metal” categories: There are 4 categories of health insurance plans: Bronze, Silver, Gold, and Platinum. These categories show how you and your plan share costs. ​ ​Bronze plans have a lower monthly premium, but you pay more if when you use it. Platinum plans have a higher monthly premium, but you pay less out of pocket when you use it. ​​
  • Your total costs for health care: You pay a monthly bill to your insurance company (a "premium"), even if you don’t use medical services that month. You pay out-of-pocket costs, including a deductible, when you get care. It’s important to think about both kinds of costs when shopping for a plan.​
  • Plan and network types — HMO, PPO, POS, and EPO: Some plan types allow you to use almost any doctor or health care facility. Others limit your choices or charge you more if you use providers outside their network.​