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To estimate what a health plan may cost you in a year, add its annual premiums to your estimated out-of-pocket spending for covered care and prescriptions. Compare that total under low-use, expected-use, and high-use scenarios; also check the plan’s out-of-pocket maximum, network, and drug coverage. HealthCare.gov advises Marketplace shoppers to compare “estimated total yearly costs” rather than premiums alone: Your total costs for health care: Premium, deductible, and out-of-pocket costs.
What to include in a yearly cost estimate
A useful comparison separates the amount you pay regardless of care from the amount that depends on the services you use.
- Annual premiums: Multiply the monthly premium by 12. Use the amount you would actually pay after any applicable subsidy. Premiums continue whether or not you receive care, and generally do not count toward the out-of-pocket maximum.
- Cost sharing: Estimate your share of covered visits, tests, procedures, and prescriptions. Depending on the plan and service, you may pay a copayment, coinsurance, or costs applied to a deductible.
- Financial risk: Note the plan’s applicable out-of-pocket maximum and which covered costs count toward it. It is a risk indicator, not a cap on premiums or every health expense.
There is no reliable universal “typical” annual total for this decision: the relevant figures depend on the specific plan, coverage year, location, and your care needs.
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Build low-, expected-, and high-use scenarios
Start by listing the care you reasonably expect in the coming year. Include regular appointments, likely tests or procedures, ongoing treatment, and prescriptions. Then estimate how each candidate plan would price those items. HealthCare.gov offers low, medium, and high expected-use estimates in its Marketplace comparison flow; your actual spending can vary with the services you use.
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| Scenario | What to include | How to use it |
| Low use | Premiums and the care you would still expect in a year with few medical needs. | Shows the cost if little care is needed; do not assume no care if you have regular prescriptions or visits. |
| Expected use | Premiums and your best estimate of the visits, treatment, and prescriptions you expect. | Provides a practical planning estimate, not a guaranteed bill. |
| High use | Premiums and a plausible year with substantially more covered care. | Helps compare potential exposure and the role of the applicable out-of-pocket maximum. |
For each scenario, calculate annual premiums plus estimated cost sharing for the care in that scenario. Keep the out-of-pocket maximum visible as a separate covered-care risk measure rather than treating it as the expected bill.
Use plan rules to estimate what each service costs
For each plan, collect its monthly premium, deductible structure, service copayments, coinsurance rates, prescription rules and tiers, and individual or household out-of-pocket maximums. Confirm the figures in that plan’s current Summary of Benefits and Coverage and its drug information.
Apply the plan’s rules service by service. A deductible is a threshold that applies according to the plan’s terms; it is not automatically an extra amount to add on top of every copay and coinsurance estimate. Some services may be covered before the deductible, different services may have separate deductibles, and prescriptions may follow distinct rules. Check the specific benefit details instead of assuming one cost-sharing rule applies to all care.
Compare the costs that the maximum does—and does not—limit
The out-of-pocket maximum can help you understand your exposure for certain covered care under the plan. It does not include premiums, and it may not protect you in the same way for out-of-network services, care the plan does not cover, or balance-billed amounts. Read the plan rules to see which costs count toward the limit and what protection applies to the care you expect to use.
Check provider access and prescription coverage
A plan with a lower estimated dollar total may still be a poor fit if it does not cover your regular care as expected. Check the plan’s current provider directory for your doctors, hospitals, and pharmacies, and verify that your prescriptions appear on its drug list at a tier and cost-sharing level you have included in your estimate. Also check whether referrals or other access rules apply.
Adapt the comparison to your coverage type
Marketplace plans
HealthCare.gov’s total-cost guidance and low-, medium-, and high-use estimates are intended for Marketplace plan comparisons. Use the current plan information for your location and coverage year.
Employer coverage
Use your employer’s plan documents and the contribution details that apply to you. Compare the amount you pay in premiums with your expected cost sharing under each available option.
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Compare costs under the Medicare coverage type you are considering. Original Medicare does not have a yearly out-of-pocket limit unless you have supplemental coverage or Medicare Advantage. Medicare plan rules and any applicable caps differ from Marketplace-plan guidance; see Medicare costs.
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Make a side-by-side worksheet
Use one row per candidate plan and keep the assumptions consistent across plans. Fill in plan-specific values from current documents, then compare the scenarios and access details.
| Plan detail | Plan A | Plan B |
| Monthly premium after applicable subsidy or employer contribution | Enter plan value | Enter plan value |
| Annual premium (monthly premium × 12) | Calculate | Calculate |
| Deductible(s), copayments, coinsurance, and prescription rules | Enter from plan documents | Enter from plan documents |
| Estimated total: low use | Annual premium + estimated cost sharing | Annual premium + estimated cost sharing |
| Estimated total: expected use | Annual premium + estimated cost sharing | Annual premium + estimated cost sharing |
| Estimated total: high use | Annual premium + estimated cost sharing | Annual premium + estimated cost sharing |
| Applicable out-of-pocket maximum and costs that count | Enter plan value and rules | Enter plan value and rules |
| Doctors, facilities, pharmacies, and medicines covered as expected | Verify in current directories | Verify in current directories |
The estimate is only as useful as its assumptions and plan details. Recheck the documents for the current year and your locality before enrolling, and treat the resulting totals as estimates rather than promises of a final bill.
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