Premiums, deductibles and out-of-pocket maximums
The premium is what you pay every month just to have insurance. The deductible is what you pay for care before the plan starts paying. The out-of-pocket maximum is the most you'll pay for covered in-network care in a year.
You'll need
- Your plan's summary of benefits, if you have one
What to know
- Premium: a monthly amount you pay whether you use care or not (HealthCare.gov).
- Deductible: with a $2,000 deductible, you pay the first $2,000 of covered services yourself. Many plans cover some things, like a checkup, before you meet it (HealthCare.gov).
- Copay and coinsurance: after the deductible, you usually pay a fixed copayment (like $20) or a percentage called coinsurance (like 20%), and the plan pays the rest (HealthCare.gov).
- Out-of-pocket maximum: once your deductible, copays and coinsurance for in-network care reach this amount, the plan pays 100% of covered benefits for the rest of the year. Premiums don't count toward it (HealthCare.gov).
Good to know
A worked example
HealthCare.gov's example: $12,000 of care, a $3,000 deductible and 20% coinsurance. You pay the $3,000, plus 20% of the remaining $9,000 ($1,800), for $4,800 total (HealthCare.gov).
The seesaw
Generally, plans with lower monthly premiums have higher deductibles, and plans with higher premiums have lower deductibles (HealthCare.gov).
What doesn't count
The out-of-pocket limit doesn't include premiums, services your plan doesn't cover, or out-of-network care (HealthCare.gov).
Sources
- HealthCare.gov Deductible
- HealthCare.gov Premium
- HealthCare.gov Out-of-pocket maximum/limit
- HealthCare.gov Coinsurance
- HealthCare.gov Copayment
Lesson M8.1 · Last checked October 2, 2026 against the sources listed. See a mistake?
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