How much will I pay?
Two things determine how much you will pay for a year of healthcare
Think of this as your monthly bill – the amount you must pay your insurance company on-time each month. It keeps your insurance active and helps cover the cost of services included in your plan – like the preventive services.
Out-of-Pocket Costs (costs when you receive healthcare)
Health insurance is designed to share costs with you when you get healthcare or prescriptions. These shared costs come in two forms—copayments (or copays) and coinsurance. When these costs apply depends on the deductible and out-of-pocket maximum.
These shared costs come in two forms:
Copayments (or copay): A fixed amount – $10 for example – you owe for a medical visit or prescription that is covered by your health plan. It is usually due when you receive the service.
Coinsurance: A percentage of the costs – 30% for example – you owe for a medical visit or prescription that is covered by your health plan. You will receive a bill for this after you receive the service.
When these costs apply depends on two key details of your plan:
Deductible: The amount you have to spend on covered healthcare services and prescriptions before your health insurance company begins to pay a percentage of your bills.
Out-of-pocket maximum: The most you’d ever have to pay for covered services and prescriptions in a plan year.
It’s helpful to think about how much you’ll pay for healthcare in terms of phases
The deductible phase starts at the beginning of the insurance plan year. When you get a prescription or medical service, you will either pay a copay or be billed for the full amount at that time, depending on your plan details. (Note: For most Health Savings Account (HSA) plans, you will pay your full bill until your deductible is met. Then copays will go into effect.)
The coinsurance phase begins after you have paid enough for healthcare services and prescriptions (not including copays) to meet your deductible. Your health insurance company will split the costs with you. You pay a percentage (typically 20-40%) of covered healthcare service or medications, and the insurance company pays the rest (typically 80–60%). Any copays continue to be paid at the time of service.
The out-of-pocket maximum phase begins after the total of all copays, prescriptions or bills for covered healthcare services (not including premiums) adds up to the out-of-pocket maximum amount for your plan. Your health insurance company pays 100% of the costs of covered services until the end of December.
Did you know?
Your gender and pre-existing conditions do NOT impact your premium amount, thanks to the Affordable Care Act. Your premium amount is based on your age, location, plan category (Bronze, Silver or Gold) and tobacco use.
Keep in mind
Premiums do NOT count toward your deductible or your out-of-pocket maximum.
Copays do not count toward your deductible, but they DO count towards your out-of-pocket maximum. Services that are delivered by out-of-network providers or are not covered by your plan benefits, do NOT count towards your deductible or out-of-pocket maximum.
Tip: Plans with a lower monthly premium have higher costs for prescriptions and healthcare at the time of care.
Planning ahead can help you save money
Consider both the monthly premium and the yearly cost estimate
To find the most cost-effective plan, it helps to consider more than just your monthly premium. Other parts of the plan can affect how much you pay for healthcare during the year. The plan with the lowest premium may not be the cheapest plan after you add up all the other costs you have. Our Quick Cost and Plan Finder tool allows you to compare both monthly premiums and the yearly cost estimates based on the information you provide.
Stay in network
Select a plan that includes your doctor as “in-network” (covered) at the location you prefer. If you go to a doctor or facility out of network, you will likely be charged the full bill, and those costs will not count toward your deductible or out-of-pocket max.
Consider generic medications
Ask your doctor if they recommend taking the generic version of a medication you are taking. Generic medications cost less and are covered by a larger number of plans which means you have more options.
Want some advice?
One of our certified brokers can answer questions while they help you choose a plan based on your specific needs and budget.
Brokers are experts in health plans, including those designed for specific health conditions. They can help you evaluate whether a plan with a higher premium that includes lower health services costs is right for you.