To estimate what a health plan may cost for a year, add its annual premiums to your expected out-of-pocket costs for covered care and prescriptions. Compare at least three scenarios—low, expected, and high use—and check the plan’s network and drug coverage as well as its prices. The result is an estimate, not a guaranteed bill: your plan’s rules, coverage year, and location all matter.
What to include in a yearly cost estimate
For Marketplace plans, HealthCare.gov advises comparing “your estimated total yearly costs for each plan – not just the premium.” HealthCare.gov’s total-cost guide describes the main components.
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- Premiums: Multiply the monthly premium by 12. Use the amount you would actually pay after any applicable subsidy. Premiums are due even in months when you do not receive care, and they generally do not count toward the out-of-pocket maximum.
- Cost sharing: Estimate what you would pay for covered visits, tests, procedures, and prescriptions under the plan’s deductible, copay, coinsurance, and drug-benefit rules.
- Financial exposure: Record the applicable out-of-pocket maximum as a risk indicator for specified covered costs, not as a limit on every health-related expense.
Gather each plan’s current details
Use the plan documents for the coverage year and location you are considering. The Summary of Benefits and Coverage explains cost sharing; the plan’s provider directory and drug list help establish whether the care and medications you expect to use are covered on the terms you need.
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- Monthly premium after any applicable subsidy and annual deductible or deductibles
- Copayments and coinsurance for likely visits, tests, and procedures
- Prescription deductible, covered drugs, and their cost tiers
- Individual and household out-of-pocket maximums, and which services count toward them
- Whether your preferred doctors, hospitals, and pharmacies are in network, plus any referral requirements
- Whether anticipated services, medications, and ongoing care are covered
Do not simply add the full deductible to every copayment and coinsurance amount. A deductible is a threshold that applies according to the plan’s service rules; some services may be covered before it is met, and different services or prescriptions may have separate rules.
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Estimate low, expected, and high use
HealthCare.gov’s Marketplace comparison flow lets shoppers consider low, medium, and high expected use. For each plan, list the care you might receive in a year, then estimate the plan’s charge for each item. Your actual costs can differ depending on which services you use and how the plan processes them.
- Low use: Include premiums and only the care you reasonably expect in a year with few visits or prescriptions.
- Expected use: List likely routine care, tests, regular prescriptions, and known follow-up visits.
- High use: Include a plausible year with substantially more care, such as additional testing, treatment, or prescriptions. Use the plan’s cost-sharing rules to estimate the covered-care exposure.
For each scenario, total annual premiums and estimated cost sharing. Keep the out-of-pocket maximum in a separate column: it helps indicate exposure for costs that count toward that limit, but it is not a substitute for estimating care.
| Plan | Low-use estimate | Expected-use estimate | High-use estimate | Applicable out-of-pocket maximum |
|---|---|---|---|---|
| Plan A | Annual premium + estimated cost sharing | Annual premium + estimated cost sharing | Annual premium + estimated cost sharing | For covered costs that count under the plan |
| Plan B | Annual premium + estimated cost sharing | Annual premium + estimated cost sharing | Annual premium + estimated cost sharing | For covered costs that count under the plan |
Fill the worksheet with each plan’s actual figures; there is no supported universal annual total that applies across plans or households. HealthCare.gov cautions that “Your actual costs will vary based on the services you use.”
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Read the out-of-pocket maximum carefully
The maximum can help compare financial risk, but it is not a cap on premiums or on every expense. Its protection depends on the plan’s rules and the services that count toward it. Out-of-network care, non-covered services, and balance-billed amounts may not receive the same protection, so check the plan documents rather than assuming those costs are included.
Compare access and coverage along with price
A lower estimate is useful only if the plan fits the care you need. Confirm that your preferred providers and facilities are in network, and check that regular prescriptions appear on the plan’s drug list at a cost tier you have included in your estimate. Also account for referral requirements where they apply. A price comparison that omits network access or medication coverage can make a plan look less costly than it will be for your household.
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Marketplace plans
The low-, medium-, and high-use comparison approach described above is based on HealthCare.gov’s Marketplace guidance. Use the current plan documents and figures for your own plan year and locality.
Employer plans
Compare the employee premium contribution and the employer plan’s own cost-sharing, network, and prescription documents. Marketplace estimates do not replace your employer plan’s terms.
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Compare the specific Medicare coverage type rather than assuming Marketplace rules apply. Original Medicare has no yearly out-of-pocket limit unless it is paired with supplemental coverage or Medicare Advantage. See Medicare’s explanation of costs and use the rules for the coverage you are evaluating.
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