Last reviewed: 3 October 2026
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Deductible, copay, coinsurance and out-of-pocket maximum: what HealthCare.gov says
The short answer: the premium is what you pay each month to have coverage.[1] The deductible, copayments, coinsurance and out-of-pocket maximum are the ways you and your plan share the cost of care. HealthCare.gov says to compare estimated total yearly costs for each plan, "not just the premium."[1]
The short version
- A premium is a monthly amount you pay for coverage whether you get services or not.[2]
- A deductible is how much you pay for certain covered services before your plan pays, except free preventive services.[1]
- Copayments and coinsurance are what you pay a provider each time you get care.[1]
- The out-of-pocket maximum is the most you spend on covered services in a year. The glossary counts deductibles, copayments and coinsurance for in-network care toward it.[1][2]
The terms, in HealthCare.gov's words
| Term | What HealthCare.gov says |
|---|---|
| Premium | "The amount you pay to your plan each month to have health insurance."[1] |
| Deductible | "How much you'll spend for certain covered health services and prescription drugs before your plan pays anything, except free preventive services."[1] |
| Copayment and coinsurance | "The amounts you pay your health care provider each time you get care, like $20 for a doctor visit or 30% of hospital charges."[1] |
| Coinsurance (glossary) | "The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible."[2] |
| Out-of-pocket maximum | "The most you'll spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services."[1] |
| Allowed amount | "The maximum amount a plan will pay for a covered health care service."[2] The glossary says it may also be called an "eligible expense," "payment allowance" or "negotiated rate." |
The $20 and 30% figures in the copayment row are HealthCare.gov's own illustrations. They are not typical or required amounts.
How they fit together: HealthCare.gov's worked example
HealthCare.gov walks through a Marketplace plan with a $1,500 deductible, 20% coinsurance and a $5,000 out-of-pocket maximum.[1] Each office visit in its example costs $125.
| Stage of the year | Jane pays | Plan pays |
|---|---|---|
| Before the deductible is met[1] | $125[1] | $0 |
| After the deductible, with 20% coinsurance[1] | $25[1] | $100[1] |
| After the out-of-pocket maximum is reached[1] | $0 | $125[1] |
HealthCare.gov notes that Jane's plan has a different deductible, coinsurance and out-of-pocket maximum for prescription drugs, and that its example shows health services only.[1]
A second example with larger costs
In the coinsurance glossary example, allowable costs are $12,000, the deductible is $3,000, coinsurance is 20% and the out-of-pocket maximum is $6,850.[2] The person pays the first $3,000, then 20% of the remaining $9,000, which is $1,800. The total is $4,800.[2] If total out-of-pocket costs reach $6,850, the glossary says you would pay only that amount.[2]
These two examples use different plans, so their dollar amounts should not be compared with each other.
Two details worth knowing
- The glossary describes the out-of-pocket maximum as applying after you spend the amount "on deductibles, copayments, and coinsurance for in-network care and services."[2]
- HealthCare.gov says that, generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.[2]
- It also says deductibles, copayments and coinsurance can add a lot to total yearly costs, "sometimes more than a plan's premium."[1]
The Summary of Benefits and Coverage
HealthCare.gov describes the Summary of Benefits and Coverage (SBC) as an easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans.[3] It says you will get an SBC when you shop for coverage on your own or through your job, renew or change coverage, or request one from the health insurance company.[3]
How to verify this yourself
Read the three HealthCare.gov pages listed below. Then find the Summary of Benefits and Coverage for the plan you are looking at and check its deductible, copayment or coinsurance, and out-of-pocket maximum. HealthCare.gov lists a help line at 1-800-318-2596.
What this page does not cover
The examples are about Marketplace plans on HealthCare.gov. We did not read guidance on other kinds of plans, so details such as separate deductibles or limits for family members, out-of-network care or prescription drugs may differ in your plan. We do not say which plan or cost level is right for anyone. This is general information, not insurance, medical or legal advice. For your own plan, ask the plan, your employer's benefits office or HealthCare.gov.
Your next step
Pick one plan you are considering. Write down its premium, deductible, copayments or coinsurance, and out-of-pocket maximum from its SBC. Then work through one example visit the way HealthCare.gov does above. Our guide to ACA enrollment periods covers when you can sign up, and our guide to health savings accounts covers one tax rule tied to high-deductible plans.
Related checks
Our standard explains how we check an agent's license and disciplinary history. Check an agent reports our findings at category level, as a method and not a verdict. Neither reviews any insurer, plan or product. To confirm the person selling you coverage is licensed, see how to check an agent's license. More plain-language guides are in the agent guides.
When we will update this page
We re-read the sources when they change. If something here is out of date, tell us. Corrections are dated on the page.
References
- [1] HealthCare.gov (U.S. Centers for Medicare & Medicaid Services), "Your total costs for health care: Premium, deductible, and out-of-pocket costs", read 3 October 2026 — healthcare.gov/choose-a-plan/your-total-costs/
- [2] HealthCare.gov (U.S. Centers for Medicare & Medicaid Services), Glossary, "Coinsurance", read 3 October 2026 — healthcare.gov/glossary/co-insurance/
- [3] HealthCare.gov (U.S. Centers for Medicare & Medicaid Services), Glossary, "Summary of Benefits and Coverage (SBC)", read 3 October 2026 — healthcare.gov/glossary/summary-of-benefits-and-coverage/
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