The four numbers that define any health plan

Ignore the marketing names. Every U.S. health plan is defined by four numbers that interact, and comparing plans means comparing all four together, not the premium alone.

  • Premium. What you pay monthly whether or not you use care.
  • Deductible. What you pay yourself before most cost-sharing begins. Preventive care is generally exempt under ACA rules.
  • Copay and coinsurance. Your share after the deductible — a flat $40 per visit, or a percentage such as 20% of the allowed amount.
  • Out-of-pocket maximum. The annual ceiling on your in-network cost sharing. Once you hit it, the plan pays 100% of covered in-network care for the rest of the year. This is the number that defines your worst case.

A plan with a low premium and a $9,000 out-of-pocket maximum is a bet that you will stay healthy. A plan with a higher premium and a $3,000 maximum is insurance against a bad year. Neither is wrong — but you should know which one you bought.

Plan types, in plain terms

HMO. You pick a primary care physician, referrals are usually required for specialists, and out-of-network care is generally not covered except in emergencies. Narrower network, lower premium.

PPO. No referral required, and out-of-network care is covered at a lower level. Broader access, higher premium.

EPO. A hybrid: no referrals needed, but no out-of-network coverage at all outside emergencies.

POS. Requires a primary care physician and referrals, but does pay something out of network.

HDHP with HSA. A high-deductible plan paired with a Health Savings Account. The IRS sets the minimum deductible and maximum out-of-pocket thresholds a plan must meet to qualify, and publishes updated HSA contribution limits every year. The tax treatment — deductible going in, tax-free growth, tax-free for qualified medical expenses — is why many people with predictable low utilization choose these.

On the ACA marketplace, plans are additionally labeled Bronze, Silver, Gold and Platinum. Those metal tiers describe actuarial value — roughly what share of total costs the plan pays across a standard population — not the quality of the network or the care.

What coverage costs right now

Employer coverage. The KFF 2025 Employer Health Benefits Survey, which interviewed 1,862 non-federal public and private firms, found average annual premiums of $9,325 for single coverage and $26,993 for family coverage. Family premiums rose 6% and single premiums 5% over the year, against 4% wage growth and 2.7% inflation. Workers contributed an average of $1,440 toward single coverage and $6,850 toward family coverage out of their own paychecks — the employer paid the rest.

ACA marketplace coverage. 2026 was a disruptive year. Marketplace insurers filed for an average premium increase of roughly 26%, split as about 30% in states using HealthCare.gov and 17% in state-run marketplaces. Separately, the enhanced premium tax credits enacted in 2021 expired at the end of 2025. KFF found that the average monthly premium payment consumers actually made, net of tax credits, rose 58% — from $113 in 2025 to $178 in 2026.

The two effects compound. If you shopped the marketplace in 2025 and renewed automatically for 2026, your net cost very likely moved more than the headline rate increase suggested.

How to choose without guessing

  1. Estimate your year, not your month. Add twelve months of premium to your realistic expected cost sharing. Then repeat the calculation assuming a bad year where you hit the out-of-pocket maximum. Compare plans on both numbers.
  2. Check the network before anything else. Verify your specific doctors, your hospital, and any specialist you see regularly — on the insurer's current directory, not last year's. Provider directories change mid-year.
  3. Check the drug formulary. If you take a maintenance medication, find its tier on each plan's formulary. A drug on tier 4 instead of tier 2 can outweigh every premium difference on the table.
  4. Re-shop the marketplace every open enrollment. The benchmark silver plan that sets your subsidy changes each year, so auto-renewal can quietly leave you in a plan that is no longer the best value for your income.
  5. Confirm your subsidy eligibility with current income. Premium tax credits are reconciled on your tax return. Estimating income too low means paying some of it back.

Protections worth knowing about

Preventive care. ACA-compliant plans must cover a defined set of preventive services in network with no cost sharing — no deductible, no copay.

Pre-existing conditions. ACA-compliant plans cannot deny coverage or charge more because of your health history.

Surprise billing. The federal No Surprises Act, effective since 2022, protects patients from most surprise out-of-network bills for emergency care and for out-of-network providers working at in-network facilities.

Note the phrase "ACA-compliant." Short-term limited-duration plans, health care sharing ministries and fixed-indemnity products are not comprehensive coverage and are not bound by these rules. They can be far cheaper because they can exclude far more.

Frequently asked questions

Not inherently. If your employer contributes to the HSA, and you can absorb the deductible from savings, an HDHP plus a funded HSA is often the lowest total-cost option for people with low predictable utilization. It is a poor fit if you could not comfortably pay the deductible in January.
The deductible is what you pay before the plan starts sharing costs. The out-of-pocket maximum is the total ceiling for the year, and it includes the deductible plus your copays and coinsurance. Premiums never count toward either.
Only with a qualifying life event — losing other coverage, marriage, birth or adoption, or a permanent move, among others. These open a special enrollment period, usually 60 days. Check HealthCare.gov or your state marketplace for the current list.
No. Metal tiers describe actuarial value — roughly how much of total costs the plan covers on average. A Bronze and a Gold plan from the same insurer can share an identical network and identical formulary.

Sources

Every figure above is drawn from the following publications. Links open on the publisher's own site.

IW

InsureWiseHub editorial team

We write plain-language explainers about U.S. insurance and cite a primary source for every number. We do not sell insurance and we are not paid by insurers. Read our editorial policy.

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