When choosing a plan, it’s a good idea to think about your total health care costs, not just the bill (the “premium”) you pay to your insurance company every month.
Other amounts, sometimes called “out-of-pocket” costs, have a big impact on your total spending on health care – sometimes more than the premium itself.
Beyond your monthly premium: Deductible and out-of-pocket costs
- Deductible: How much you have to spend for covered health services before your insurance company pays anything (except free preventive services)
- Copayments and coinsurance: Payments you make each time you get a medical service after reaching your deductible
- Out-of-pocket maximum: The most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.
How to estimate your total costs of care
In order to pick a plan based on your total costs of care, you’ll need to estimate the medical services you’ll use for the year ahead. Of course it’s impossible to predict the exact amount. So think about how much care you usually use, or are likely to use.
If you preview plans and prices before logging into HealthCare.gov, you can choose each family member’s expected medical use as low, medium, or high. When you view plans, you’ll see an estimate of your total costs — including monthly premiums and all out-of-pocket costs — based on your household’s expected use of care.
Your actual expenses will vary, but the estimate is useful for comparing plans’ total impact on your household budget. This will help you pick a plan — and a plan category — based on the total costs of care you expect, not just your monthly premium.
Total costs & “metal” categories
When you compare plans in the Marketplace, the plans appear in 4 “metal” categories: Bronze, Silver, Gold, and Platinum. The categories are based on how you and the health plan share the total costs of your care.
Generally speaking, categories with higher premiums (Gold, Platinum) pay more of your total costs of health care. Categories with lower premiums (Bronze, Silver) pay less of your total costs. (But see the exception about Silver plans below.)
So how do you find a category that works for you?
- If you expect a lot of doctor visits or need regular prescriptions: You may want a Gold plan or Platinum plan. These plans generally have higher monthly premiums but pay more of your costs when you need care.
- If you don’t expect to use regular medical services and don’t take regular prescriptions: You may want a Silver, Bronze, or Catastrophic plan. These plans cost you less per month, but pay less of your costs when you need care.
- If you qualify to save on out-of-pocket costs: Silver plans may offer the best value. If you qualify for “cost-sharing reductions” based on your income, you can have a lower deductible and pay lower out-of-pocket costs when you get care — but only if you enroll in Silver plan.
