The good news is there is often a limit to how much you may have to pay out-of-pocket. Your plan may have an "out-of-pocket maximum." Once you reach that amount, you will not have to pay any more out-of-pocket costs for the year.

You will still have to pay a monthly insurance premium, no matter what services are used.

All plans are different. Plans may include all or only some of these ways to share costs with you:

• Copayment. This is the payment you make for certain health care provider visits and prescriptions, typically at the time of service. It is a set amount, like $15. Your plan may also include different copayment (copay) amounts for preferred vs. non-preferred drugs or providers. This can range from $10 to $60 or more.
• Deductible. This is the total amount you have to pay for medical services before your health insurance will start to pay. For example, you may have a plan with a $1,250 deductible. You would then need to pay $1,250 out-of-pocket during the plan year before your insurance company will start to make payments.
• Coinsurance. This is a percentage you pay for each visit or service. For example, 80/20 plans are common. For an 80/20 plan, you pay 20% of the cost for each service you receive. The plan pays the remaining 80% of the cost. Coinsurance may begin after you have paid your deductible. Keep in mind that your plan may have a maximum allowable limit for each cost of service. Sometimes providers charge more, and you may have to pay that extra amount as well as your 20%.
• Out-of-pocket maximum. This is the maximum amount of co-pays, deductible, and coinsurance you will have to pay in a plan year. Once you reach your out-of-pocket maximum, the plan pays 100%. You will no longer have to pay coinsurance, deductibles, or other out-of-pocket costs.

In general, you do not pay anything for preventive services. These include vaccines, annual wellness visits, flu shots, and certain health screening tests.

You may need to pay some form of out-of pocket costs for:

• Emergency care
• Inpatient care
• Provider visits for an illness or injury, such as an ear infection or knee pain
• Specialist care
• Imaging or diagnostic visits, such as x-rays or MRIs
• Rehab, physical or occupational therapy, or chiropractic care
• Mental health, behavioral health, or substance abuse care
• Hospice, home health, skilled nursing, or durable medical equipment
• Prescription drugs
• Dental and eye care (if offered by your plan)

Choose the right type of health plan based on your location, health, and other preferences. Get to know your benefits, such as how they relate to emergency room visits and network providers.

Choose a primary care provider who helps guide you to only the tests and procedures you need. Also ask about lower-cost facilities and medicines.

Understanding your health care costs can help you save money when managing your care.

Healthcare.gov website. Understanding health insurance costs makes for better decisions. www.healthcare.gov/blog/understanding-health-care-costs/. Updated July 28, 2016. Accessed August 8, 2022.

HealthCare.gov website. Understanding your health coverage. www.healthcare.gov/blog/understanding-your-health-coverage. Updated July 25, 2014. Accessed August 8, 2022.

HealthCare.gov website. Your total costs for health care: premium, deductible & out-of-pocket costs. www.healthcare.gov/choose-a-plan/your-total-costs. Accessed August 8, 2022.

Updated by: Linda J. Vorvick, MD, Clinical Professor, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington, Seattle, WA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.