How Much Are Healthcare Out of Pocket Costs? (Copayment)

When you receive healthcare services, your plan may require you to pay a copayment right then and there.  Whether you will have to pay a copayment and the dollar amounts of the copayment depend on the specific health coverage plan that you've chosen.

The amount of the overall cost that will come out of your pocket also depends on your specific plan.  In general, the higher the type of metal plan you choose, the more you will pay in premiums and the less you will pay out-of-pocket.  For example, the bronze plan splits covered expenses approximately 60-40, meaning the insurance company would pay 60% of covered costs, on average for everyone on the plan, while policy holders pay 40% out-of-pocket on average.  In comparison, the platinum plan splits covered expenses approximately 90-10.

This doesn't mean each copay will be that % of a service, it means over all plan participants the combined cost sharing paid will be about that %. Some plans can cover 60% of out-of-pocket costs on average without having any cost sharing (you pay full out-of-pocket for covered services). This is due to the way maximum works.

Obamacare regulates out-of-pocket maximums - the most you can be required to pay out of your pocket in a specific coverage period.  In 2015, your out-of-pocket maximum can be no more than $6,600 for an individual plan and $13,200 for a family plan.  However, if you make less than 250% the Federal Poverty Level, you may qualify for Cost Sharing Reduction Subsidies which will lower your out-of-pocket maximums.

In short on a lower premium plan you should expect to pay full out-of-pocket costs, on better plans you'll pay less if anything at all. What you do pay in copays is applied to your deductible and out-of-pocket maximum.