What is the deductible and out of pocket maximum on a Marketplace plan?
The two numbers that decide what a plan really costs you, and why the cheapest premium often is not the cheapest plan.
Premium is what you pay to have the plan. The deductible and the out of pocket maximum are what you pay to use it. People shop on the first number and get hurt by the other two.
The deductible
What you pay yourself before the plan starts sharing most costs. On a bronze plan it can be several thousand dollars. On a gold plan it is usually much lower.
Not everything waits for the deductible. By law, preventive care is covered at no cost from day one: annual wellness visits, immunizations, screenings for blood pressure, cholesterol, diabetes, and cancer screenings including mammograms and colonoscopies.
Many plans also cover primary care visits and generic drugs at a copay before the deductible is met. That detail matters more than the deductible number itself, so read it.
Copays and coinsurance
After the deductible, you share costs with the plan. A copay is a fixed amount, say a set dollar figure for an office visit. Coinsurance is a percentage of the bill.
Coinsurance is the one to watch. Twenty percent of a hospital stay is a very different number from a flat copay.
The out of pocket maximum
The most you can pay in a plan year for covered in network care. Once you reach it, the plan pays 100 percent of covered services for the rest of the year.
This is the most important number on the plan and the least advertised. It is your worst case. Insurance exists for the bad year, and this figure is what the bad year costs you. Compare it before you compare premiums.
Premiums do not count toward it. Out of network care usually does not count either, and neither does anything the plan does not cover.
How to compare two plans honestly
- Twelve months of premium, after the credit. That is your floor.
- Add the deductible. That is roughly a moderate year.
- Add the out of pocket maximum instead. That is your worst case.
- Check your doctors are in network and your prescriptions are covered.
- If you qualify for cost sharing reductions, look hard at silver, because that is the only level where they apply.
A bronze plan with a low premium and a high deductible often costs more across a real year than a silver plan. See how the metal levels work and why a zero premium plan is not free.
Family plans have two sets
Family coverage usually has both an individual and a family deductible, and the same for the out of pocket maximum. One person can meet the individual amount and start getting cost sharing even if the family total has not been reached.
Ask how the plan handles this. It varies and it matters if one family member uses much more care than the others.
Common follow-up questions
Does my premium count toward the out of pocket maximum?
No. Premiums are separate. Only deductibles, copays and coinsurance on covered care count.
Is preventive care free before the deductible?
Yes. In network preventive services are covered with no cost sharing regardless of your deductible.
Which matters more, deductible or out of pocket maximum?
The maximum, because it defines your worst year. The deductible matters more for how a normal year feels.
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