ACA health insurance
Deductible vs. out-of-pocket maximum: the two numbers that decide your bills
The deductible is what you pay before the plan starts sharing costs for many services. The out-of-pocket maximum is the most you pay in a year for covered, in-network care. The second number is the one that protects you in a bad year.
How they work together
Suppose a plan has a deductible and also copays. Some services, such as certain preventive visits, may be covered before you meet the deductible. Others you pay in full until you meet it.
After you reach the out-of-pocket maximum, the plan pays 100 percent of covered in-network care for the rest of the year. Premiums and out-of-network costs generally do not count.
How to compare
- Add the yearly premium to the out-of-pocket maximum to see the most you could pay in a very bad year.
- Add the yearly premium to your likely care costs to see the likely cost in a typical year.
- Check whether prescriptions have their own deductible.
Have this ready when you call
- A list of the care you expect this year
- Your medicine list
- Your doctors' names
Common questions
Does the premium count toward the deductible?
No. Premiums are separate from your deductible and out-of-pocket maximum.
Is a lower premium better?
Not always. A low premium often goes with a high deductible, which can cost more if you use care.
Related answers
Rather talk it through?
Call 855-367-1095 and a licensed agent will go through your situation with you. There is no charge to ask, and no obligation to enroll.
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Information on this site is educational and does not guarantee eligibility, enrollment, pricing, or availability. It is not a recommendation to buy any specific plan or policy.