Premium, Deductible and Network: The Health Plan Trade-off

Choosing a health plan means balancing four things: what you pay every month, what you pay when you use care, the most you could pay in a year, and which doctors you can see. Understanding each one makes the comparison much easier.

The four costs to compare

• Premium — what you pay every month to keep the plan, whether or not you use it.
• Deductible — what you pay for covered care each year before the plan starts sharing the cost. Many plans cover some preventive care before the deductible.
• Copays and coinsurance — your share after the deductible. A copay is a fixed amount, such as for a doctor visit; coinsurance is a percentage of the bill.
• Out-of-pocket maximum — the most you will pay for covered in-network care in a year. After you reach it, the plan pays 100% of covered costs for the rest of the year.

The basic trade-off: a lower premium usually means a higher deductible, and the other way around.

Metal tiers

Marketplace plans are grouped by how costs are split between you and the plan:

• Bronze — lowest premiums, highest costs when you get care
• Silver — moderate premiums and costs
• Gold — higher premiums, lower costs when you get care
• Platinum — highest premiums, lowest costs when you get care

If you rarely see a doctor, a lower premium may save money. If you expect regular care, ongoing prescriptions or a planned procedure, a plan with a lower deductible often costs less overall.

Networks: HMO, PPO and EPO

• HMO — usually covers only in-network care, except emergencies, and often needs a referral to see a specialist.
• PPO — covers out-of-network care too, at a higher cost, and usually does not need referrals.
• EPO — covers only in-network care, except emergencies, but usually does not need referrals.

A cheaper plan is no bargain if your doctor is not in its network. Check your doctors, nearby hospitals and pharmacies before you choose.

High-deductible plans and HSAs

Some high-deductible plans qualify you to open a health savings account (HSA). You can put money in before tax, it can grow, and withdrawals for qualified medical costs are tax-free. If you are healthy and can set money aside, this can be a good combination.

How to decide

1. Estimate how much care you expect next year.
2. Make sure your doctors and prescriptions are covered.
3. Add up the yearly premium plus what you would likely pay in care.
4. Check the out-of-pocket maximum — it is your worst-case year.

This guide is general information. Plan details vary — always check the plan's summary of benefits before you enroll.