Deductible is what you pay before insurance starts covering.

Out-of-pocket (OOP) maximum is the total most you pay per year including deductible, copays, and coinsurance.

Example: $2,000 deductible, $8,000 OOP max - you pay first $2,000 fully, then coinsurance until reaching $8,000 total, then insurance pays 100%. 2025 ACA limits: $9,450 individual / $18,900 family OOP maximum.

Choose based on expected usage: High-deductible (HDHP): Lower premiums, HSA eligible, best if healthy and rarely need care.

Example: $1,600 deductible, $300/month premium.

Low-deductible: Higher premiums, better for chronic conditions or planned procedures.

Example: $500 deductible, $600/month premium.

Break-even analysis: If annual medical costs <$2,000, HDHP saves money.

If >$5,000, low-deductible better.

Add HSA tax savings ($1,000+ value) to HDHP advantage.

Counts toward both: copays, coinsurance, and deductible payments for covered services.

Does NOT count: monthly premiums, out-of-network care (usually), non-covered services, charges above plan allowed amounts.

Important: preventive care (annual checkup, vaccines, screenings) is 100% covered before deductible under ACA.

Some plans apply copays before deductible is met.

Metal tiers show insurance payment percentage: Bronze 60% (you pay 40%), Silver 70% (30%), Gold 80% (20%), Platinum 90% (10%).

Trade-offs: Bronze: Lowest premiums ($400/month), highest deductibles ($7,000+), best for healthy.

Silver: Moderate ($550/month), $4,000 deductible, qualifies for cost-sharing reductions if income <250% FPL.

Gold: Higher premiums ($700/month), lower deductibles ($1,500), best for regular care.

Platinum: Highest premiums ($850/month), minimal cost-sharing, best for chronic conditions.

HSA (Health Savings Account) is tax-advantaged savings for medical expenses.

Triple tax benefit: contributions tax-deductible, growth tax-free, withdrawals tax-free for medical expenses. 2025 qualification requires HDHP with: $1,600+ individual / $3,200+ family deductible, $9,450/$18,900 OOP maximum, no other coverage. 2025 contribution limits: $4,300 individual / $8,550 family, plus $1,000 age 55+ catch-up.

Funds roll over forever, become retirement account after 65.

Calculate: (Monthly premium × 12) + Expected out-of-pocket costs.

Expected OOP by health status: Healthy (1-2 visits/year): $500-1,500, Moderate (chronic condition, regular prescriptions): $3,000-5,000, High utilization (surgery, specialists, ongoing treatment): Hit OOP max $9,450.

Do not forget: prescription costs, specialist copays, emergency room visits.

Conservative approach: assume reaching 50% of deductible minimum.

Compare total cost across plan options, not just premiums.