Costs Explained

How much you pay for health care depends on your monthly premium and out-of-pocket costs.

  • You pay a monthly premium to your insurance company to keep your plan active.
  • You also pay out-of-pocket costs when you get care. These costs include co-pays and co-insurance.
    • Co-pays are set amounts you pay for medical visits or prescriptions. 
    • Co-insurance is a percentage of the cost of the service. How much you pay in co-insurance may change during the year. It depends on:
  • How much care you have already received and its cost.

A year in costs: A step-by-step example

For example, let's look at how "Jane" pays for care during the year. Jane's Bronze Level plan has:

  • a $5,000 deductible
  • 20% co-insurance
  • a $9,200 out-of-pocket maximum
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When the year starts

Costs reset at the start of each year, or when you first are enrolled in a plan. At first, you must pay the full cost of your care until you reach your deductible.

Early in the year, Jane goes to the doctor for an injury. 

  • Because she has not paid any of her deductible yet, she must pay the full allowed amount for the visit, x-rays and prescription.
  • She does not pay co-insurance yet.
  • She has not met her out-of-pocket maximum.

After you meet your deductible

Once you have met your deductible, you start paying co-insurance. You split the cost with your insurance company. What you pay depends on your plan and whether you see an in-network provider.

By the end of the summer, Jane has had a few more doctor visits, an outpatient surgery, and more prescriptions.

  • Jane has paid $5,000 for in-network care, so she has met her deductible.
  • Now she pays co-insurance. She pays 20% of the allowed amount for her next treatment, and her insurance company pays 80%.
  • She will keep paying co-insurance until she reaches her out-of-pocket maximum.

After you meet your out-of-pocket maximum

After you reach your out-of-pocket maximum, your plan pays all costs for covered services for the rest of the year. You must use in-network providers for the plan to pay.

By late in the year, Jane has paid $9,200 for medical care and prescriptions (not including co-pays). She has reached her out-of-pocket maximum.

  • Jane met her deductible earlier in the year.
  • She paid co-insurance until she reached her out-of-pocket maximum.
  • For the rest of the year, her insurance pays 100% of the allowed amount when Jane sees in-network providers.

For more information

  • Contact your health insurance company
  • Review your plan’s summary of benefits and coverage