The four terms in plain English
| Term | What it means |
|---|---|
| Premium | What you pay every month to have the plan, whether you use it or not. |
| Deductible | What you pay for covered care before the plan starts sharing the cost. Many plans cover preventive care, and often some visits, before the deductible. |
| Copay | A flat fee for a service, like $30 for a doctor visit or $15 for a generic drug. |
| Coinsurance | Your percentage of the bill after the deductible, like 20%. |
| Out-of-pocket maximum | The most you'll pay for covered in-network care in a year. After you hit it, the plan pays 100%. |
A simple example
Say your plan has a $3,000 deductible, 20% coinsurance and a $7,000 out-of-pocket maximum. You need surgery that costs $40,000 at the plan's negotiated rate.
- You pay the first $3,000 (deductible).
- On the remaining $37,000, you'd owe 20%, or $7,400, but…
- Your out-of-pocket maximum caps your total at $7,000. So you pay $4,000 more, and the plan pays everything else.
Total you pay for the year: $7,000 plus premiums. Without insurance, that same surgery could cost you the full $40,000 or more.
How to compare plans the smart way
Don't compare premiums alone. Estimate your total yearly cost in two scenarios:
- A normal year: 12 months of premium plus the visits and prescriptions you usually use.
- A bad year: 12 months of premium plus the out-of-pocket maximum.
If you rarely see a doctor, a lower premium with a higher deductible may win. If you have ongoing prescriptions, a chronic condition or a baby on the way, a higher premium with lower cost-sharing often costs less overall.
Metal tiers, quickly
ACA plans are grouped by how much of the average person's costs they cover: Bronze (lowest premium, highest costs when you use care), Silver, Gold and Platinum (highest premium, lowest costs at the doctor). If your income qualifies for cost-sharing reductions, a Silver plan can come with a much lower deductible, so check before choosing Bronze.
What about HSAs?
A Health Savings Account lets you set aside pre-tax money for medical costs if you have an HSA-eligible plan. For 2026 the contribution limits are $4,400 for self-only coverage and $8,750 for family coverage, plus a $1,000 catch-up at 55 or older. Starting in 2026, federal law also treats Bronze and catastrophic Marketplace plans as HSA-compatible, which opens HSAs to many more people buying their own coverage.
Frequently asked questions
Do copays count toward the deductible?
Usually not, but they almost always count toward the out-of-pocket maximum.
Does the premium count toward the out-of-pocket maximum?
No. Premiums are separate.
Want us to run the numbers?
We'll compare plans on total yearly cost based on your doctors and prescriptions.
Get a QuoteGeneral information only, not tax advice. Figures are examples. Check your plan's Summary of Benefits and Coverage and talk to a tax professional about HSAs.