Deductible, copay, coinsurance and out-of-pocket max
Four words decide what a doctor visit or a hospital stay really costs you. One example ties them together.
Last checked October 14, 2026 · Written by licensed advisors · Sources are numbered and listed under Notes and sources
What is a deductible in health insurance?
A deductible is the amount you pay for covered care each year before your health plan starts to pay its share. Some services, such as many preventive visits, are covered before you meet it.12
- What you pay first, each year
- Before the plan pays its share
- Some preventive care is covered before it
- Resets every plan year
The four words
Premium: what you pay every month to have the plan, whether you use it or not.
Deductible: what you pay for covered care each year before the plan starts sharing the cost. Many preventive visits are covered before you meet it.
Copay and coinsurance: your share after the deductible. A copay is a flat amount, such as $40 for a visit. Coinsurance is a percentage, such as 20% of a hospital bill.
Out-of-pocket maximum: the most you pay in a year for covered, in-network care. After you reach it, the plan pays 100% for the rest of the year. Premiums don’t count toward it.12
- Every monthPremium: you pay it to keep the plan
- Until the deductibleYou pay for covered care, except many preventive visits
- After the deductibleCopays or coinsurance: you share the cost
- Out-of-pocket maximumThe plan pays 100% of covered in-network care for the rest of the year (key step)
One example
Say your plan has a $5,000 deductible, 20% coinsurance and an $8,000 out-of-pocket maximum, and a hospital stay costs $30,000.3
| Step | You pay | Plan pays |
|---|---|---|
| The first $5,000 (deductible) | $5,000 | $0 |
| 20% of the next $15,000 | $3,000 | $12,000 |
| Max reached: the plan pays the rest | $0 | $10,000 |
| Total for the stay | $8,000 | $22,000 |
The 2027 limit
For 2027, the most any Marketplace plan can make one person pay out of pocket is $12,000, up from 2026. Many plans set their own maximum lower. A family plan’s limit is twice that.2
How to use this when you choose
A low premium with a high deductible is fine if you rarely need care and could cover the deductible in a bad year. If you couldn’t, a higher metal level, or a silver plan with extra savings, or supplemental coverage that pays you cash toward the deductible, can close the gap.4
What to do: Ask yourself: could I pay this plan’s deductible tomorrow? If not, tell us, and we will show you the options that lower it.
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Obamacare Hotline and/or Medicare Po Polsku are private companies not affiliated with any local, state, or federal government agency. This guide is general information, not tax or legal advice.