Updated July 2026 · Reviewed by the CoverageCo team
Four numbers decide what a health plan costs you: the premium you pay monthly, the deductible you pay before the plan shares costs, the copays and coinsurance you pay per service, and the out-of-pocket maximum that caps your yearly spending. After you hit that maximum, the plan pays 100% of covered care.
Key takeaways
- Premium is what you pay to have coverage; the other three are what you pay to use it.
- A low premium usually means a high deductible — you're choosing when to pay, not whether.
- The out-of-pocket maximum is your worst-case number for the year on covered, in-network care.
- Preventive care is often covered at no cost, even before you meet the deductible.
The four numbers that decide what you pay
These four terms do most of the heavy lifting on any plan.
- Premium — what you pay every month to have the plan, whether you use it or not.
- Deductible — what you pay yourself before the plan starts sharing most costs.
- Copay / coinsurance — your share of a visit or service after the deductible (a flat copay like $30, or a percentage like 20%).
- Out-of-pocket maximum — the most you'll pay in a year. After you hit it, the plan covers 100% of covered care.
How they work together
Think of it as a sequence. You pay your premium every month no matter what. When you get care, you first pay toward your deductible. After that, you and the plan share costs through copays or coinsurance. Once your total spending hits the out-of-pocket maximum, the plan picks up everything else for the rest of the year.
That out-of-pocket maximum is the real safety net — it caps your worst-case year.
Networks matter just as much
Every plan has a network of doctors and hospitals it has agreements with. Staying in-network keeps your costs down; going out-of-network can cost a lot more.
- HMO — usually lowest cost, but you stick to the network and often need a referral for specialists.
- PPO — more flexibility to see who you want, usually a higher premium.
- EPO — a middle ground: network-only, but often no referrals needed.
- POS — a mix of HMO and PPO rules.
Before you enroll, check two things
Always confirm your doctors are in the plan's network and your prescriptions are on its drug list before you sign up. A plan with a low premium isn't a deal if your doctor isn't covered. We check both for you, for free, before you enroll.
Common questions
What's the difference between a deductible and an out-of-pocket maximum?
The deductible is what you pay before the plan starts sharing most costs. The out-of-pocket maximum is the most you'll pay in a year for covered in-network care — once you reach it, the plan pays 100%.
Does my copay count toward my deductible?
It depends on the plan. Copays often count toward your out-of-pocket maximum but not always toward your deductible. Check the plan's summary of benefits.
What is coinsurance?
Your percentage share of a covered cost after you've met the deductible — for example, you pay 20% and the plan pays 80%.
Do I pay the deductible before preventive care?
Usually no. Marketplace plans generally cover in-network preventive services like screenings and vaccines at no cost, even before you meet your deductible.