For Consumers

What are my out-of-pocket costs?

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

The type of individual health plan you buy determines out-of-pocket costs
Metal levelPlan paysYou pay

Bronze*

60%

40%

Silver

70%

30%

Gold

80%

20%

Platinum

90%

10%

*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 2020, out-of-pocket costs (deductible, copayments and coinsurance) are limited to $8,200 for self-only coverage and $16,400 for family coverage.

Once you meet the limit, your health plan starts to pay 100% 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.