What is a Deductible?

A deductible is a dollar amount your health insurer may require you to pay out-of-pocket each year, before your health plan begins to pay for covered medical expenses. For 2027, the highest out-of-pocket maximum allowed on an ACA plan is $12,000 for an individual and $24,000 for a family ($10,600 and $21,200 for 2026), and a plan’s deductible cannot be higher than its out-of-pocket maximum.

Example: Judy's deductible on her plan is $1,500 with 80/20 coinsurance with a $6,850 out-of-pocket maximum. Judy will pay out-of-pocket for all medical expenses (unless covered by a copay) up to $1,500. Once Judy covers $1,500 in expenses, Judy will pay 20% and her plan will pay 80% of her remaining medical care until Judy's reaches her $6,850 out-of-pocket maximum. The out-of-pocket maximum includes her deductibles, copays, and her coinsurance amount paid.

The deductible typically applies to major services such as MRIs, surgery, hospitalizations. If your plan has a copay benefit, you typically only pay your copay benefit for that visit unless a follow up procedure or service is recommended.

If your plan does not include a copay benefit such as an HSA plan, any office visit or medical procedure that is not a preventive visit will count towards your deductible.

If you see your primary care doctor for a preventive visit, your visit will always be covered at 100% at no charge to you.