For Assistance Call Consumers for Affordable Health Care:

Cost and Cost Sharing

When deciding what type of plan you want, consider your total health care costs, not just what you pay for your monthly premium. These other costs, called the “out-of-pocket” costs, can have a big effect on your total spending each year. When shopping for a plan, it is important to know that each plan can have different out-of-pocket costs. These costs include:
  • Deductible: how much you have to spend for covered health services before the insurance company pays anything. This doesn’t apply to preventative services, which are free.
  • Copayments: a flat fee paid directly to the provider when you receive a medical service. For example, $20 paid for every visit to the doctor.
  • Coinsurance: amount of percent that you have to pay for most medical care even after you meet your deductible. For example, some insurance plans pay 80% of the claim so your coinsurance or bill would be 20%.
  • Out-of-pocket maximum (OOPM): a predetermined, limited amount of money you have to pay each year for deductibles and coinsurance. The amount is set by the insurance company. It is the maximum or most money you have to spend on covered services each year. Once you reach that amount, the insurance company pays 100% of those covered services, except for copays.

When deciding which plan is best for you, you should try to estimate what medical services you anticipate using in the year ahead, keeping in mind that no one can predict exactly, but think about what you usually use. To get an estimate, you could multiply the monthly plan premium by 12 and then add the out of pocket amount to see what the most you could have to pay in a year.

You can preview plans by going to healthcare.gov/see-plans. When you look at the different plans offered, you will see an estimate of what your total costs would be for each plan. Your actual costs will vary but it can be helpful when choosing a plan to have that information.

TYPES OF FINANCIAL HELP

Advance Premium Tax Credits: When you fill out a Marketplace application, you’ll find out if you qualify for advance premium tax credits (APTCs). If you qualify, APTCs can be used to lower your monthly insurance premium when you enroll in a plan through the Health Insurance Marketplace. The amount of your tax credit is based on the income estimate and household information you put on your Marketplace application.

If your estimated income falls between 138% and 400% of the federal poverty level for your household size, you qualify for a premium tax credit.

You can use all, some, or none of your premium tax credit in advance to lower your monthly premium. It is important to know that if you use more advance payments of the tax credit than you qualify for based on your final yearly income, you must repay the difference when you file your federal income tax return. You can buy health insurance through other sources, but the only way to get a premium tax credit is through the Health Insurance Marketplace.

Cost Sharing Reductions (CSR): are discounts that lower out-of-pocket costs that you have to pay for deductibles, copayments, and coinsurance. CSR also lower out of pocket maximum for those eligible. To qualify, you must enroll in a Silver plan. Eligibility for CSR are based on income on a sliding scale for a smaller income range than for the APTCs.

Levels of Plans Plans on the Health Insurance Marketplace fall into three levels or metal types: bronze, silver and gold. A limited number of people may be able to buy a fourth type called catastrophic.

Bronze plans have the most cost-sharing for covered benefits, and gold plans require the least cost-sharing. In other words, a bronze plan would cover roughly 60% of the cost for an average population and enrollees (on average) would pay 40%. For a gold plan, an average individual would pay 20% out of pocket for their covered benefits and the plan would pay about 80%.

Certain people can buy “catastrophic” plans that cover essential benefits but have very high deductibles. Those who can purchase catastrophic coverage are young adults, under age 30. Adults over age 30 can buy catastrophic plans with a hardship exemption or because there is no available affordable coverage.