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- Anyone comparing two plans with different deductibles and copays
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Home / Insurance / Health Insurance Deductibles, Copays & Coinsurance
Insurance · Updated 2026-10-19
Health Insurance Deductibles, Copays & Coinsurance Explained
Verified Oct 19, 2026Your premium buys the plan. Cost-sharing — deductibles, copays, and coinsurance — is what you pay when you actually use care. These three mechanisms, plus the out-of-pocket maximum that caps them, decide your real yearly cost far more than the premium does.
The definitions below come from HealthCare.gov's official glossary. Once you see how the pieces fit together, comparing two plans becomes arithmetic instead of guesswork.
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The deductible: what you pay first
The deductible is 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.
Two important nuances: many plans cover certain services — like checkups — before the deductible is met, and all Marketplace plans pay the full cost of certain preventive benefits even before you've met the deductible. The national average general annual deductible for single coverage is $1,886, per KFF's 2025 survey.
The copay: a fixed price per service
A copayment (copay) is a fixed amount — say, $20 — you pay for a covered service after you've paid your deductible. Copays vary by service: a primary care visit, a specialist visit, lab tests, and prescription drugs can each carry a different copay.
Copays are the most predictable part of cost-sharing. When a plan advertises '$25 primary care visits,' that's the copay — but check whether it applies before or after the deductible, because that detail changes what you pay.
Coinsurance: your percentage of the bill
Coinsurance is the percentage of a covered service's cost you pay after you've paid your deductible — 20%, for example. If a covered procedure costs $1,000 and you've met your deductible, 20% coinsurance means you pay $200 and the plan pays $800.
Coinsurance is where big bills come from: unlike a flat copay, a percentage of a large bill is a large number. This is exactly what the out-of-pocket maximum exists to cap.
The out-of-pocket maximum: your safety net
The out-of-pocket maximum (or limit) is the most you'll pay for covered, in-network services in a plan year. After you reach it, the plan pays 100% of covered benefits for the rest of the year.
For 2026, the ACA caps the out-of-pocket maximum for Marketplace plans at $10,600 for an individual and $21,200 for a family. (HHS revised its 2026 methodology mid-cycle — an earlier published figure of $10,150/$20,300 was superseded, and HealthCare.gov's glossary confirms the revised numbers.) For 2027 the cap rises to $12,000 individual / $24,000 family.
How the pieces fit together: a walk-through
Imagine a plan with a $2,000 deductible, 20% coinsurance, and a $6,000 out-of-pocket maximum. You need a $10,000 covered surgery:
- You pay the first $2,000 (deductible).
- Of the remaining $8,000, you pay 20% coinsurance = $1,600.
- Your total so far: $3,600 — below the $6,000 max, so you pay all of it.
If instead you needed $50,000 of care, your deductible plus coinsurance would blow past $6,000 — but the out-of-pocket maximum stops your share at $6,000, and the plan pays the rest of covered costs.
Preventive care plays by different rules
Most health plans must cover a set of preventive services — like screening tests — at no cost to you when they're in-network, with no copay or coinsurance even before you've met your deductible. Marketplace plans follow the same rule.
This is the cheapest care in the system: annual checkups, recommended screenings, and immunizations don't touch your deductible. Skipping them to 'save money' saves nothing and risks everything.
What doesn't count toward the maximum
The out-of-pocket maximum doesn't include everything. Per HealthCare.gov, it excludes your monthly premiums, anything spent on services your plan doesn't cover, out-of-network care, and costs above the allowed amount for a service.
Translation: the maximum caps your share of covered, in-network care. Going out of network or using non-covered services can still cost you beyond it — another reason the network check matters before you enroll.
Key costs, at a glance
| What | Figure | Source |
|---|---|---|
| 2026 ACA out-of-pocket maximum, individual | $10,600 | HealthCare.gov — Glossary (out-of-pocket maximum/limit) as of 2026 plan year (revised HHS methodology) |
| 2026 ACA out-of-pocket maximum, family | $21,200 | HealthCare.gov — Glossary (out-of-pocket maximum/limit) as of 2026 plan year (revised HHS methodology) |
| Average general annual deductible, single coverage | $1,886 | KFF — 2025 Employer Health Benefits Survey as of 2025 (released Oct 2025) |
Averages mask wide state-by-state variation. Your premium depends on your profile, location, and coverage choices.
Who it's best for — and who can skip it
You may not need it if
- Anyone who only needs the premium averages — see the cost guide
How to compare
- Add deductible + expected copays/coinsurance, not just the premium
- Check the out-of-pocket maximum — it's your worst-case number
- Confirm whether copays apply before or after the deductible
- Verify preventive services are covered in-network at no cost
- Remember premiums, non-covered services, and out-of-network care don't count toward the max
Your next step
Find your plan's four numbers — deductible, copay schedule, coinsurance rate, and out-of-pocket maximum — and run the walk-through math above for a $10,000 care year. If a high-deductible option is on the table, the HDHP and HSA guide shows how the savings-account half works.
Health Insurance Deductibles, Copays & Coinsurance FAQs
What is a deductible in health insurance?
The amount you pay for covered health care services before your plan starts to pay. With a $2,000 deductible, you pay the first $2,000 of covered services yourself. The national average for single coverage is $1,886, per KFF's 2025 survey.
What's the difference between a copay and coinsurance?
A copay is a fixed dollar amount per service (e.g., $20 for a visit); coinsurance is a percentage of the cost (e.g., 20%) that you pay after meeting your deductible. Copays are predictable; coinsurance scales with the bill.
What is the out-of-pocket maximum?
The most you'll pay for covered, in-network services in a plan year. After you hit it, the plan pays 100% of covered benefits. For 2026, Marketplace plans cap it at $10,600 individual / $21,200 family.
Do I still pay my premium after hitting the out-of-pocket maximum?
Yes. Monthly premiums never count toward the out-of-pocket maximum — you keep paying them all year. The maximum also excludes non-covered services, out-of-network care, and amounts above the allowed amount.
Do I pay for preventive care before meeting my deductible?
No, as long as it's in-network. Most plans — including all Marketplace plans — must cover recommended preventive services at no cost to you, with no copay or coinsurance, even before the deductible is met.
Why do some sources list a different 2026 out-of-pocket maximum?
HHS revised its 2026 methodology mid-cycle: an earlier published figure of $10,150 individual / $20,300 family was superseded by $10,600 / $21,200. HealthCare.gov's glossary confirms the revised numbers — use those.
Sources
Every figure on this page comes from the official source named. We never use aggregator sites as sources.