I'm choosing a plan
Premium, deductible, out-of-pocket maximum — which one matters?
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All three matter, but the out-of-pocket maximum matters most in a bad year. Add a year of premiums to the out-of-pocket maximum to see the most you could pay for covered in-network care.
What to do
- Write down three numbers for each plan: the monthly premium (what you pay to have the plan), the deductible (what you pay before the plan starts paying), and the out-of-pocket maximum (the most you pay for covered care in a year).
- Multiply the premium by 12 and add the out-of-pocket maximum to get your worst-case cost for in-network care.
- Estimate a typical year too: premiums plus what you usually spend on visits and medications.
- Check what does not count toward the maximum, such as the premium itself and, usually, out-of-network care.
- Pick the plan whose worst case you could actually afford, then compare the typical years.
What to say
Can you tell me the deductible and the out-of-pocket maximum for in-network care, and whether copays and prescriptions count toward the maximum?
Ask the plan, your employer's benefits office, or a SHIP counselor before you enroll, and ask for the answer in writing.
What to watch out for
Every situation is differentIf you’d like a second pair of eyes on yours, book a free 15-minute call.
Choosing the lowest premium without looking at the out-of-pocket maximum. A cheap monthly plan can leave you with a very large bill in the year you actually need care.
Better done together
We’re here to help
The numbers only mean something once they are matched to your health, your medications and your doctors. We sit down with you, run the numbers for a normal year and a hard year, and show you how to compare plans so you can do it yourself next time.
Every situation is different, and these are sensitive moments, so we look at yours with care. We often see what others miss, and we never take commissions from insurance companies: the only thing we are working for is what is right for you.
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The rule behind it
Insurance companies and job-based plans must give you a Summary of Benefits and Coverage (SBC) (45 CFR 147.200). It lists your premium, deductible and out-of-pocket maximum in a standard format. Federal law caps what you pay each year for in-network covered care. For 2026, HealthCare.gov lists the limit for Marketplace plans as $10,600 for one person and $21,200 for a family. Medicare Advantage plans also have a yearly limit, but Original Medicare has none, which is why many people add a Medigap policy.
Sources
- HealthCare.gov — Summary of Benefits and Coverage
- 45 CFR 147.200 — Summary of benefits and coverage
- HealthCare.gov — Out-of-pocket maximum/limit
- Medicare.gov — Compare Original Medicare and Medicare Advantage
Amanda Alcodia
Education, not medical, legal or insurance advice.
Useful next steps
Start with the free Kit. If your situation needs a person, the intro call is free too.