For Consumers

What are my out-of-pocket costs?

The type of individual health plan you buy will determine your out-of-pocket costs:

Metal levelPlan paysYou pay

Bronze*

60 percent

40 percent

Silver

70 percent

30 percent

Gold

80 percent

20 percent

Platinum

90 percent

10 percent

*Bronze plans have the minimal level of coverage you need to meet the requirement to have health insurance.

What you should know before you buy

The health insurance costs not covered by your plan must be paid by you, so make sure you know before you make an appointment or receive services.

  • Ask about your premium amount and out-of-pocket costs (such as copayments, deductibles and coinsurance).
  • Understand how the claims process works, how your providers get paid and what portion you have to pay.
  • Ask if your providers are in the insurance company's network.
  • Ask if your medications are covered and their costs

You and your family may qualify for assistance if you can't afford health coverage.

Limits on out-of-pocket costs

For 2017, out-of-pocket costs (deductible, copayments and coinsurance) are limited to $7,150 for self-only coverage ($6,850 in 2016) and $14,300 for a family plan ($13,700 in 2016).

Once you meet the limit, your health plan starts to pay 100 percent of your allowed amount for a covered benefit.

Note: Neither your premiums, or costs for medical services not covered by your health plan, count toward your plan’s out-of-pocket limit.