Cost Sharing

Cost sharing is the portion of your medical bills you pay yourself, separate from your monthly premium. It's made up of three things: your deductible, your copays, and your coinsurance.

Your premium buys the coverage. Cost sharing is what you pay when you actually use it.

Here's how the three pieces work together. Say you have a $1,500 deductible, a $30 primary care copay, and 20% coinsurance. You pay the first $1,500 of covered care yourself. After that, a routine doctor visit costs you $30 instead of the full billed amount, and a $400 specialist procedure costs you $80 while your plan covers $320.

Cost sharing has a ceiling. Everything you pay in deductible, copays, and coinsurance counts toward your out-of-pocket maximum. Once you reach it, your plan covers 100% of covered in-network services for the rest of the plan year. The federal ceiling for 2027 is $12,000 for an individual and $24,000 for a family, up from $10,600 and $21,200 in 2026.

Two things do not count as cost sharing: your monthly premium, and anything you spend out-of-network on a plan that doesn't cover out-of-network care.

The tradeoff between premium and cost sharing is the central decision in plan shopping. Bronze plans have the lowest premiums and the highest cost sharing. Platinum plans invert that. Neither is automatically better; it depends on how much care you expect to use. If your income is at or below 250% of the Federal Poverty Level, a Silver plan with Cost-Sharing Reductions lowers all three components at once, which is usually the strongest value available.