Comparing the cost of care: What to consider beyond the monthly premium

When shopping for individual Health Insurance Marketplace^® plans, many people start by asking, "What will my monthly premium be?"

It's an important question, but a plan’s premium is just one thing you should consider when selecting a plan — and the lowest-premium plan isn't always the best value.

In some cases, a plan with a higher premium may result in lower overall costs if you expect to use medical services or take prescription medications regularly.

Consider each plan’s overall value, including how well it fits your health care needs, budget, and comfort level with financial risk.

Know the costs you’re comparing

To understand the full cost of care, consider both what you pay to have health coverage and what you may need to pay when you use it:

• Monthly premium: The amount you pay each month for health coverage.
• Deductible: The amount you pay before your plan starts sharing certain health care costs.
• Copay: A fixed amount you pay for a covered service or prescription.
• Coinsurance: A percentage of the cost you pay for covered services after you meet your deductible.
• Prescription drug costs: What you pay for covered prescription medications.
• Out-of-pocket maximum: The most you'll pay for covered health care costs during a plan year.

Start with your expected health care needs

Think about the care you and your family may need in the coming year:

• How often do I visit the doctor?
• Do I see any specialists?
• Do I take ongoing prescription medications?
• Am I managing a chronic condition?
• Am I expecting a major life event, such as having a baby?
• Could my health care needs change in the coming year?

If you're generally healthy and rarely visit the doctor, you may prioritize a lower monthly premium. If you regularly use health care services, manage a chronic condition, or take prescription medications, a plan with lower costs when you receive care may be a better fit.

Marketplace plans are grouped into metal tiers that balance monthly premiums and out-of-pocket costs differently. As you compare Bronze, Silver, and Gold options, consider how each plan's cost structure aligns with your expected needs.

Consider what you’ll pay when you need care

The out-of-pocket maximum is also an important form of financial protection.  A lower out-of-pocket maximum may provide greater protection and peace of mind if you experience a serious illness or injury.

As you compare plans, don't just ask, “What will I pay each month?” Also ask, “What could I owe if I need significant medical care?”

Check who and what the plan covers

Cost matters, but so does access to the care and medications you use. Provider networks and prescription coverage can differ by plan.

Before choosing health coverage, check:

• Whether your primary care doctor, specialists, and preferred hospitals are in-network
• Whether your medications are covered and what they will cost
• Whether preferred pharmacy options are available

Reviewing provider and prescription coverage can help prevent disruptions in care, avoid unexpected costs, and increase confidence in your coverage choice.

Considering alternative coverage? Understand the tradeoffs

We know health coverage costs are a real concern for many individuals and families. Choosing a lower-premium plan can reduce what you pay each month, but it's important to understand how costs, provider access, prescription coverage, and financial protection may differ. Before switching, compare what you may save with what could change when you need care.

How much will I save each month? Start by comparing the premium difference between plans.

What will I pay if I need care? A lower-premium plan may have a higher deductible, higher copays or coinsurance, or a higher out-of-pocket maximum.

Is this a local network plan? Some lower-premium options include a smaller choice of high-quality doctors, specialists, and hospitals. If opting for a local network plan, check that your providers are covered.

Are my prescriptions covered? Check whether your medications are included and what you would pay under the new plan.

How much financial risk am I comfortable taking on?  Consider what you could owe if an unexpected health need arises, not only what you will pay each month.

For some people, a lower-premium option may provide the right balance between monthly cost and coverage. For others, paying more each month may offer lower costs when receiving care or greater financial protection during the year.

Choose health coverage based on total value

Don’t forget to compare plans based on total value, not just the monthly premium.

Consider your expected health care needs, prescription costs, deductibles, copays, coinsurance, provider access, and protection from unexpected medical expenses.

The right plan should fit your budget, support your health needs, and help you feel more confident about your coverage.

Learn more about Open Enrollment.