How to Read a Health Plan's Deductible and Cost Table
The short answer: every marketplace plan shows the same grid of costs on HealthCare.gov and in its Summary of Benefits and Coverage (SBC). Read it in this order: the out-of-pocket maximum (your worst case), the deductible (what you pay first), then each service row to see whether it says "after deductible" or "deductible does not apply." That one phrase decides whether a $40 copay really costs $40.
A sample plan, row by row
This is an illustration, not a real Tennessee plan. Real plans use the same wording.
| What the table says | Example | What it means for you |
|---|---|---|
| Deductible | $6,000 individual / $12,000 family | You pay the full negotiated price for most care until you've paid this much in a year. |
| Out-of-pocket maximum | $9,800 individual / $19,600 family | The most you pay for covered in-network care in a year. After that the plan pays 100%. |
| Preventive care | No charge | Free in network, even before the deductible. |
| Primary care visit | $40 copay, deductible does not apply | You pay $40 from day one. |
| Specialist visit | $80 copay after deductible | You pay the full price until the deductible is met, then $80. |
| Urgent care | $75 copay | Usually means the deductible doesn't apply, but check the SBC. |
| Emergency room | 40% coinsurance after deductible | Full price until the deductible, then 40% until you hit the maximum. |
| Inpatient hospital stay | 40% coinsurance after deductible | Same as above. A hospital stay often reaches the out-of-pocket maximum. |
| Generic drugs | $15 copay | You pay $15 per fill. |
| Preferred brand drugs | $60 copay after drug deductible ($500) | A separate, smaller deductible applies to drugs. |
| Specialty drugs | 50% coinsurance after deductible | High-cost drugs; check the formulary and prior authorization rules. |
| Out-of-network | Not covered | Typical for HMOs and EPOs. Only emergencies are covered out of network. |
The phrases that trip people up
"Copay after deductible." The copay only starts once you've met the deductible. Before that, you pay the plan's full negotiated rate for the visit.
"Copay, deductible does not apply" (or just a dollar amount with no mention of the deductible). You pay the copay from the first visit. Plans with several services like this are friendlier for people who see doctors often but don't expect big bills.
"No charge after deductible." Free once the deductible is met. Before that, you pay the full rate.
"Coinsurance." A percentage of the negotiated price. 40% of a $3,000 MRI is $1,200.
"Separate drug deductible." Some plans have a second, smaller deductible just for prescriptions. Some combine drugs with the medical deductible.
"Integrated" deductible. Medical and drug costs count toward one deductible.
Individual vs. family deductibles
Family plans list two numbers, like "$6,000 individual / $12,000 family."
- Embedded deductible (most common on marketplace plans): each person has their own $6,000 deductible inside the $12,000 family deductible. If one family member has a big year, the plan starts sharing costs for that person after $6,000, even if no one else has spent anything. Once the family together reaches $12,000, the deductible is met for everyone.
- Non-embedded (aggregate) deductible: the whole family has to reach the family amount before the plan shares costs for anyone. This is more common on HSA-style plans.
Out-of-pocket maximums work the same way. Federal rules require that no single person on a family plan pays more than the individual out-of-pocket limit, which is $12,000 in 2027.
The SBC says which kind of deductible the plan uses. Look for the word "embedded," or an example like "each family member meets their own deductible."
What counts toward the deductible and out-of-pocket maximum
| Cost | Counts toward deductible? | Counts toward out-of-pocket maximum? |
|---|---|---|
| Monthly premiums | No | No |
| What you pay before the deductible is met | Yes | Yes |
| Copays | Usually no (check the SBC) | Yes |
| Coinsurance | No (it starts after the deductible) | Yes |
| Out-of-network care on a plan that doesn't cover it | No | No |
| Services the plan doesn't cover | No | No |
How to estimate a plan's total yearly cost
The cheapest premium is often not the cheapest plan. For each plan you're considering, add:
- Premiums: your monthly premium after the tax credit, times 12.
- Expected care: the visits, prescriptions, and tests you're fairly sure you'll need, priced using the table above.
- A bad-year check: premiums times 12, plus the out-of-pocket maximum. That's your worst case.
HealthCare.gov also shows an estimated total yearly cost for each plan based on whether you expect low, medium, or high use. Use both: the estimate for a typical year, and the bad-year number to make sure you could survive it.
Example: Plan A costs $50 a month with a $7,500 deductible; Plan B costs $160 a month with a $2,000 deductible. In a healthy year, A costs $600 and B costs $1,920. If you need surgery, A's worst case might be $600 + $9,800 = $10,400 and B's $1,920 + $6,000 = $7,920. Which is "cheaper" depends on how likely the bad year is and whether you have savings to cover it.
If your income is between 100% and 250% of the poverty level, run this comparison with a silver plan first. Cost-sharing reductions can shrink a silver plan's deductible to a few hundred dollars. Estimate yours.
HDHPs and health savings accounts (HSAs)
A high-deductible health plan (HDHP) is a plan that qualifies you to put money in a health savings account. Money you put in an HSA is tax-deductible, grows tax-free, and comes out tax-free for qualified medical costs. Unused money rolls over every year and stays yours.
| 2026 | 2027 | |
|---|---|---|
| Minimum HDHP deductible | $1,700 self / $3,400 family | $1,750 self / $3,500 family |
| Maximum HDHP out-of-pocket | $8,500 self / $17,000 family | $8,700 self / $17,400 family |
| HSA contribution limit | $4,400 self / $8,750 family | $4,500 self / $9,000 family |
| Catch-up contribution (55+) | $1,000 | $1,000 |
New since 2026: under the 2025 budget law, every bronze and catastrophic plan available through the marketplace counts as HSA-compatible, even if it doesn't meet the usual HDHP rules. That holds whether you buy the plan on HealthCare.gov or directly from the insurer. People in certain direct primary care arrangements can also contribute to an HSA.
HSA contributions also lower your MAGI, the income figure used for marketplace tax credits. For someone near the 400% cliff, that can matter a lot. The full HSA guide →
Other things to check in the table
- Quality ratings. HealthCare.gov shows 1 to 5 stars for many plans, based on member surveys and clinical quality. Useful as one factor, not the deciding one.
- Limits and exclusions. The SBC lists services the plan doesn't cover and any visit limits, such as a cap on physical therapy visits.
- Coverage examples. Every SBC includes standardized examples (having a baby, managing diabetes, a simple fracture) showing what you'd pay. They're a quick way to compare plans on the same terms.
Frequently asked questions
What's the Summary of Benefits and Coverage (SBC)? A standardized, plain-language document every health plan must provide. It shows the deductible, out-of-pocket maximum, what you pay for common services, what isn't covered, and worked coverage examples. Find it in the plan details on HealthCare.gov or on the insurer's website before you enroll.
How does a family deductible work? Most marketplace family plans use an embedded deductible: each person has an individual deductible inside the family deductible. One person's costs start getting shared once they hit the individual amount, and everyone is covered once the family total is met. Check the SBC to confirm.
Do copays count toward my deductible? Usually not, but they do count toward your out-of-pocket maximum. The plan's SBC says for sure.
Is the plan with the lowest premium the most affordable? Often not. A low premium usually means a higher deductible and higher costs when you get care. Compare the total yearly cost: premiums plus the care you expect, and check the worst case (premiums plus the out-of-pocket maximum).
How much will I pay if I end up in the hospital? Typically your deductible, then coinsurance on the rest, up to your out-of-pocket maximum. A multi-day hospital stay often reaches the maximum. After that, covered in-network care is free for the rest of the plan year.
Can I use an HSA with a marketplace plan? Yes, with any bronze or catastrophic marketplace plan (starting in 2026), and with other plans that meet the HDHP rules. You open the HSA yourself at a bank or HSA provider.
Are there hidden fees? ACA plans show their costs in the SBC. The surprises usually come from out-of-network providers, services the plan doesn't cover, or non-ACA products: Farm Bureau plans require membership dues, and some short-term plans charge association or enrollment fees.
Keep reading
- Deductible, copay, coinsurance, out-of-pocket max: how they fit together
- Marketplace plan tiers, compared
- The plan comparison checklist
- Premium tax credit estimator
Sources
- HealthCare.gov — Summary of Benefits and Coverage, plan details, estimated total yearly cost, quality ratings
- CMS — 2027 maximum out-of-pocket limits ($12,000 individual / $24,000 family) and the rule that no individual on a family plan pays more than the individual limit
- IRS Revenue Procedure 2026-24 (via Navia Benefits summary) — 2027 HSA and HDHP limits; Rev. Proc. 2025-19 for 2026
- IRS Notice 2026-05 and news release IR-2025-119 (December 9, 2025) — bronze and catastrophic plans treated as HSA-compatible starting 2026; direct primary care
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