What health insurance covers

The deductible is what you pay before the plan shares cost, though preventive care and, on many plans, primary-care visits and generic drugs are covered before it with a flat copay. After the deductible you pay coinsurance, a share of the allowed amount, until your spending for the year reaches the out-of-pocket maximum; from there the plan pays covered in-network care in full until the plan year resets. Family plans carry both an individual and a family figure for each. Suppose a plan has a $3,000 deductible and a $7,000 out-of-pocket maximum: a hospital stay billed at $40,000 would cost you the deductible plus coinsurance up to $7,000 and no more, which is the number to plan a budget around, not the premium.

Marketplace plans are grouped into bronze, silver, gold and platinum by roughly what share of the total cost of care the plan pays across everyone enrolled. Bronze has the lowest premium and the highest deductible; platinum the reverse; silver and gold sit between. Silver is special on the marketplace: households below an income ceiling get cost-sharing reductions that shrink a silver plan's deductible and maximum without changing the premium, which can make silver pay better than gold for them. The tier is not a measure of network size or provider quality, only of the cost split.

An HMO covers care only from its network, needs a primary-care physician and referrals to specialists, and pays nothing outside the network except emergencies. A PPO pays for out-of-network care at a lower share and without referrals, for a higher premium. An EPO uses a network like an HMO but usually without referrals. Networks in the individual market are narrower than employer networks, and they differ plan by plan even within the same carrier, so the first step in any comparison is checking whether your doctors and your hospital are in the specific plan's network, not the carrier's.

Each plan has a formulary that lists covered drugs in tiers, from generics with a small copay up to specialty drugs paid by coinsurance after the deductible. A drug that is not on the formulary is paid in full by you unless an exception is approved. Prior authorisation, step therapy and quantity limits apply to some drugs, and mail-order pricing is often lower for maintenance medications. We run your prescriptions against each plan's formulary before recommending one.

Plans sold directly by carriers off the marketplace follow the same rules but carry no tax credit. Short-term medical plans are not ACA plans: they can decline applicants, exclude pre-existing conditions and cap benefits, and their allowed duration is set by federal rule and by each state. They can bridge a gap between jobs for someone healthy, and they are a poor substitute for a full plan. Supplemental policies, such as accident, critical illness and hospital indemnity, pay a fixed cash amount on an event and are used to blunt a high deductible rather than to replace a health plan.