ON EXCHANGE - Depending on the family income, you may qualify for subsidies from the Federal and State to help you pay the insurance premium.

OFF EXCHANGE - Buy the insurance plan without any financial help. This option is for the family with a higher income or does not file a tax return. 

 Healthcare Terms

Copayment

A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor's visit is $20.

• If you've paid your deductible: You pay $20, usually at the time of the visit.

• If you haven't met your deductible: You pay $100, the full allowable amount for the visit.

Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.

Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.

Deductible

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.

• Many plans pay for certain services, like a checkup or disease management programs, before you've met your deductible. Check your plan details.

• All Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible.

• Some plans have separate deductibles for certain services, like prescription drugs.

• Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members.

Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.

Co-Insurance

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.

• If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.

• If you haven't met your deductible: You pay the full allowed amount, $100.

Example of coinsurance with high medical costs

Let's say the following amounts apply to your plan and you need a lot of treatment for a serious condition. Allowable costs are $12,000.

• Deductible: $3,000

• Coinsurance: 20%

• Out-of-pocket maximum: $6,850

You'd pay all of the first $3,000 (your deductible).

You'll pay 20% of the remaining $9,000, or $1,800 (your coinsurance).

So your total out-of-pocket costs would be $4,800 — your $3,000 deductible plus your $1,800 coinsurance.

If your total out-of-pocket costs reach $6,850, you'd pay only that amount, including your deductible and coinsurance. The insurance company would pay for all covered services for the rest of your plan year.

Generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.

Out-of-pocket maximum/limit

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

The out-of-pocket limit doesn't include:

• Your monthly premiums

• Anything you spend for services your plan doesn't cover

• Out-of-network care and services

• Costs above the allowed amount for a service that a provider may charge

The out-of-pocket limit for Marketplace plans varies, but can’t go over a set amount each year.

• For the 2023 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $9,100 for an individual and $18,200 for a family.

• For the 2022 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,700 for an individual and $17,400 for a family.

The health plans come in four metal tiers. They have different costs for premiums and services — but the same great benefits.  

Healthcare Related Links