Money · Insurance
Premiums, deductibles and out-of-pocket maximums
The premium is your monthly bill just to have coverage. The deductible is what you pay for covered care before the plan pays (many plans cover a checkup before that). After it, you pay a copayment (like $30) or coinsurance (like 20%). The out-of-pocket maximum caps your in-network costs for the year: for 2026 Marketplace plans, no more than $10,600 for one person. Premiums, uncovered care and out-of-network care don't count toward it. Compare plans on premiums times 12 plus what you'd pay in a bad year.
You'll need
- Each plan's Summary of Benefits and Coverage (SBC)
- A rough idea of how much care you use: visits, prescriptions, anything planned
What to know
- Premium: a monthly amount you pay for coverage whether you use care or not. Source: HealthCare.gov2 Multiply by 12 for the yearly cost.
- Deductible: with a $2,000 deductible, you pay the first $2,000 of covered services yourself. Many plans pay for some services, like a checkup, before you meet it, and all Marketplace plans fully cover certain preventive care. Some plans have a separate deductible for prescriptions. Source: HealthCare.gov1
- Copay and coinsurance: after the deductible, you usually pay a fixed copayment, like $30, or coinsurance, a percentage like 20%, and the plan pays the rest. Source: HealthCare.gov1 If the plan's allowed amount for a visit is $100 and your coinsurance is 20%, you pay $20 once you've met your deductible, and the full $100 if you haven't. Source: HealthCare.gov4
- Out-of-pocket maximum: once your deductibles, copays and coinsurance for in-network care reach this amount, the plan pays 100% of covered benefits for the rest of the plan year. Source: HealthCare.gov3 For Marketplace plans it can be no more than $10,600 for one person or $21,200 for a family in 2026, and $12,000 or $24,000 in 2027. Source: HealthCare.gov3
- Know what doesn't count toward the max: your premiums, services the plan doesn't cover, out-of-network care, and charges above the plan's allowed amount. Source: HealthCare.gov3
- Get the SBC for every plan you're considering. Insurers and job-based plans must give you this short, plain-language Summary of Benefits and Coverage, which makes apples-to-apples comparisons possible. You can ask for it any time. Source: HealthCare.gov5
HealthCare.gov's worked example
A serious illness with $12,000 of allowed costs, a $3,000 deductible, 20% coinsurance and a $6,850 out-of-pocket max. Source: HealthCare.gov4
| Step | You pay |
|---|---|
| The deductible | $3,000 |
| 20% of the remaining $9,000 | $1,800 |
| Total | $4,800, under the $6,850 max |
Premiums are on top of this.
Comparing two plans
A made-up example to show the math. Use the real numbers from each plan's SBC.
| Plan A: low premium | Plan B: higher premium | |
|---|---|---|
| Premium | $50 a month ($600 a year) | $150 a month ($1,800 a year) |
| Deductible | $5,000 | $1,000 |
| Coinsurance after deductible | 20% | 20% |
| Out-of-pocket max | $7,000 | $4,000 |
| Light year: $500 of care | $600 + $500 = $1,100 | $1,800 + $500 = $2,300 |
| Bad year: $20,000 of care | $600 + $7,000 max = $7,600 | $1,800 + $4,000 max = $5,800 |
Plan A wins if you're healthy. Plan B wins if something big happens. Ask yourself whether you could pay Plan A's max if you had to.
Marketplace metal levels
The levels have nothing to do with quality of care, only how costs are split. These are estimates; real costs vary by plan. Source: HealthCare.gov6
| Level | Plan pays | You pay | Deductible |
|---|---|---|---|
| Bronze | 60% | 40% | High |
| Silver | 70% | 30% | Moderate |
| Silver with extra savings | 73% to 96% | 6% to 27% | Low |
| Gold | 80% | 20% | Low |
| Platinum | 90% | 10% | Low |
Catastrophic plans, where available, are for people under 30 or with a hardship exemption. Extra savings, based on income, only come with Silver plans. Source: HealthCare.gov6
See it done
Video by Khan Academy Nonprofit
Health insurance costs
Full title on YouTube: “Health insurance costs | Insurance | Financial mathematics (TX TEKS) | Khan Academy”2026 · Checked October 3, 2026
Video won't load at school or work? No problem. Everything you need is in the steps; the video's just a bonus. Watch it on YouTube later.
If it doesn't work
- Choosing a high-deductible plan? If it's HSA-eligible, you can put pre-tax money in a Health Savings Account for deductibles, copays and coinsurance. HSA money generally can't pay premiums, and its earnings aren't taxed. Source: HealthCare.gov7 All Bronze and Catastrophic Marketplace plans work with HSAs. Source: HealthCare.gov6
- Got a bill for more than you expected? Check whether the provider was in network, and whether the charge is above the plan's allowed amount. Neither counts toward your max. Source: HealthCare.gov3
Good to know
The details, if you want them. Tap a line to open it.
The seesaw
Generally, plans with lower monthly premiums have higher deductibles, and plans with higher premiums have lower deductibles. Source: HealthCare.gov1
Family plans
Family plans often have both an individual deductible for each person and a family deductible for everyone. Source: HealthCare.gov1
SBC coverage examples
Every SBC shows what the plan would cover in two common situations, diabetes care and childbirth, which is a quick way to compare plans. Source: HealthCare.gov5
Take it with you
Printable cardDownload card (PDF)Sources
- HealthCare.gov Deductible
- HealthCare.gov Premium
- HealthCare.gov Out-of-pocket maximum/limit
- HealthCare.gov Coinsurance
- HealthCare.gov Summary of Benefits and Coverage
- HealthCare.gov Health plan categories
- HealthCare.gov Health Savings Account
Lesson M8.1 · Last checked October 2, 2026 against the sources listed.
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