The four numbers on every plan, what you actually pay when you get care, and how to compare two plans by what a bad year would cost, with the 2026 limits and what employers really charge.
The premium is the price of having the plan, taken from your paycheck or paid each month. The deductible is how much of your own care you pay for in full each year before the plan starts sharing costs. After that, copays are flat fees for things like a doctor's visit, and coinsurance is a percentage of the bill. The out-of-pocket maximum caps what you pay for covered in-network care in a year; premiums never count toward it.
| Employer plans, 2025 averages | Single | Family |
|---|---|---|
| Total yearly premium | $9,325 | $26,993 |
| Part the worker pays | $1,440 | $6,850 |
| Deductible, where there is one | $1,886 | — |
| Primary care copay | $27 | — |
| Coinsurance, where it applies | 19% | — |
Most of the premium is usually paid by the employer: in 2025 the average single plan cost $9,325 a year, of which workers paid $1,440. Preventive care, such as a yearly checkup and recommended screenings, is covered without a deductible or copay when you use an in-network provider.
Take a plan with a $2,000 deductible, 20% coinsurance, a $30 copay for doctor visits and a $5,000 out-of-pocket maximum, and follow one person through a year. Copays count toward the out-of-pocket maximum but not the deductible here, which is common:
| Care during the year | Negotiated price | You pay | Your running total |
|---|---|---|---|
| Three doctor visits | $450 | $90 | $90 |
| An MRI | $1,500 | $1,500 | $1,590 |
| Surgery | $20,000 | $3,410 | $5,000 |
| Premiums for the year | — | $1,440 | $6,440 |
The MRI falls entirely inside the deductible. The surgery uses up the last $500 of it, and 20% of the rest would be $3,900, but the out-of-pocket maximum stops the bill at $3,410. Without the surgery the year would have cost $3,030 including premiums; with it, $6,440, and not a dollar more however large the hospital bill. That cap only applies to covered care from in-network providers, so the network matters as much as the numbers.
A plan with a lower premium usually has a higher deductible. The fair way to compare two plans is to add the premiums to the cost of a quiet year, and again to the out-of-pocket maximum for a bad one. Two illustrative plans:
| Traditional plan | High-deductible plan | |
|---|---|---|
| Your premiums for the year | $1,440 | $600 |
| Deductible | $1,000 | $1,700 |
| Out-of-pocket maximum | $4,000 | $5,000 |
| A quiet year ($300 of care) | $1,740 | $900 |
| The worst year | $5,440 | $5,600 |
Here the high-deductible plan saves $840 in a quiet year and costs $160 more in the worst one. It also comes with a health savings account: money put in through payroll skips income tax, Social Security and Medicare, so $1,000 saved there costs someone in the 22% bracket about $703.50 of take-home pay, and it can be spent on care tax-free in any later year.
Limits are the federal figures for 2026: the Affordable Care Act's out-of-pocket ceiling from the Department of Health and Human Services, and the high-deductible plan and HSA limits from the IRS. Averages are from KFF's 2025 survey of employer health benefits. The example plans are illustrations, not real products.
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