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Understanding Health Insurance Costs

Woman putting coins in a piggy bank.

Premiums, copays, coinsurance, deductibles — they all play an important part in your coverage and health care bills.

Once you understand health insurance costs and how they all work together, you'll be able to find the right plan to fit your budget. We'll also look at ways you might be able to get help paying for them.

 

What Costs Can You Expect With Your Plan?

Premium

A premium is the amount you (or your employer) pay for your health insurance plan. You'll have a premium payment whether you use medical services or not. In most cases, it's paid monthly, but you may have the option to pay it every three months or yearly.

Deductible

A deductible is the amount you must pay before the health plan starts paying for your covered services. For example, if your deductible is $1,000, your plan won't pay for some services until you've paid $1,000. In most cases, the higher your deductible, the lower your premium. Similarly, the lower your deductible, the higher your premium.

Learn 8 things you should know about deductibles.

Tip for choosing your premium and deductible

If you'll be using your insurance often, you may want to choose a plan with a higher premium and lower deductible. This means you'll pay more each month, but the amount you pay when you go to the doctor will be less over the course of the year.

If you won't use your insurance often, you may want to choose a plan with a lower monthly premium and higher deductible. You may be able to keep your monthly costs low if you don't have health care costs, like deductible payments, from doctor visits or health care services.

Coinsurance vs. Copay

Coinsurance is a percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.

For example, let's say it costs $100 to see your doctor. If your coinsurance is 20%, you pay $20 and the insurance plan pays $80. If you haven't met your deductible, you must pay the entire amount.

A copay is a fixed dollar amount you may have to pay at the time you get care. In most cases, it's a small amount, such as $20 for a doctor's exam. You won't always have to pay a copay. The amount you pay depends on your health plan and which doctor you see.

Learn the difference between coinsurance and copays.

Out-of-Pocket Maximum

This is the most you will pay out of your own pocket for expenses under your insurance plan during the year. Deductibles, coinsurance, copays and other expenses for in-network essential health benefits (EHBs) apply to the out-of-pocket maximum.

Learn the basics of out-of-pocket maximums.

Stay In Network With Provider Finder®

Before you go for care, make sure you go to a doctor or hospital in your health plan network. In-network providers have agreed to work with your health plan to keep costs down. If you visit a doctor outside your network, you may have to pay more for your care. In some cases, you may have to pay the full cost.

Search for in-network care.

Get Help Paying For Health Insurance

Under the Affordable Care Act, you may be able to get help paying for your health insurance through one or both of these options:

  1. Premium tax credit: A credit that lowers your monthly premium for your individual and family health insurance premium if you qualify. Understand premium tax credits.
  2. Cost-sharing assistance: A discount that lowers the amount you pay for your deductible, coinsurance and copays.

To qualify for savings:

  • Your income must be within a certain range for your household size.
  • You can't be claimed as a dependent on someone else's tax return.
  • You can't be eligible for a government-sponsored program or an employer-sponsored health insurance plan.
  • You must buy a plan on the Health Insurance Marketplace from the Silver plan category.

To learn if you qualify for savings, enter your ZIP code, income and family size when you're ready to enroll on our shopping platform.

Low or No-Cost Health Insurance Government Program

Based on your income and family size, you may be able to get low or no-cost health insurance through a government program, like Medicaid or the Children's Health Insurance Program (CHIP).

You can apply online. If you qualify for Medicaid or CHIP, the proper government office will contact you.

Please note: If you sign up for Medicaid or CHIP, you will not be able to use a premium tax credit or cost-sharing discount. If you have Medicaid coverage now, you're considered covered under the health care law and don't have to buy a plan on the Marketplace.

You may qualify for Medicaid or CHIP now.