How to compare two health plans beyond the premium

The short answer

The monthly premium is only part of what a plan costs. For each plan, add up a whole year: 12 months of premiums plus what you expect to pay when you use care (the deductible, copays and coinsurance). For covered care from in-network providers, that second part stops at the plan's out-of-pocket maximum. Work out a likely year and a bad year for each plan. Then check what a price cannot show you:

1. Are your doctors, hospital and pharmacy in the plan's network?
2. Is each of your medicines on the plan's drug list, and at what cost?
3. Which rules, such as referrals or approval before care, apply to the care you need?

The plan with the lowest premium is not always the cheapest plan for your year.

Gather these before you compare

Plans and insurers must send you an SBC within seven business days of your request.

Step 1: Learn the five numbers that set your costs

A few rules change the math:

• Preventive care is often free. Many screenings, checkups and vaccines cost nothing with an in-network provider, even before the deductible, though $0 is not guaranteed in every case. Free preventive care under your insurance explains when a "free" visit can still produce a bill.
• There is a federal ceiling. For most plans, the out-of-pocket maximum can be no higher than $10,600 for one person and $21,200 for a family in 2026, and $12,000 and $24,000 in 2027. Many plans set lower limits. High-deductible plans built to work with a health savings account (HSA) have a lower 2027 ceiling: $8,700 for one person and $17,400 for a family. Marketplace Bronze and catastrophic plans count as HSA-compatible even when their limits are higher.
• In a family plan, each person also has a limit. Under federal rules for marketplace plans and most job-based plans, no one person in a family plan pays more than the federal limit for one person ($12,000 in 2027). Many plans, including Covered California's standard plans, stop each person's costs at the plan's own individual out-of-pocket maximum.

Step 2: Estimate a year with each plan

Yearly cost = (12 × monthly premium) + expected cost sharing

"Cost sharing" is what you pay toward care: deductible, copays and coinsurance. For covered, in-network care, it never goes above the plan's out-of-pocket maximum. Out-of-network care and services the plan does not cover are added on top.

Work out two versions for each plan:

• A likely year. Count the visits, tests and prescriptions you expect, based on last year and anything already planned.
• A bad year. Add 12 months of premiums to the full out-of-pocket maximum. That is about the most you would pay for covered, in-network care after a serious illness or injury.

HealthCare.gov's plan preview can add an estimated yearly cost for low, medium or high use of care. In California, Covered California's plan comparison tool also shows an estimated yearly cost. Treat their results as estimates. The health plan total-cost worksheet walks through the arithmetic line by line, with more examples.

Plan A costs $1,260 less in a likely year; Plan B costs $1,700 less in a bad year. If he could not pay $9,500 in a hard year, Plan B's lower ceiling may be worth the higher premium.

Step 3: Check the network, not just the company

A network is the group of doctors, hospitals, labs and pharmacies that have agreed to a plan's prices. The plan type tells you how strictly the plan sticks to it.

• Search each plan's directory for every doctor you want to keep, plus your hospital, lab and pharmacy. One company can sell several plans with different networks, so use the exact plan name.
• Call each office and ask, "Do you take [exact plan name] for next year?" Directories can be out of date. How to find a primary care doctor who is accepting new patients has a call script.
• Note the date and what the directory or member services line told you. Under federal law, if you relied on a plan's directory or phone answer that wrongly listed a provider as in network, the plan generally may charge you no more than in-network cost sharing.
• If you are pregnant, in the middle of treatment or see a specialist often, ask each plan how it would handle your ongoing care before you switch.

Step 4: Check every medicine on the drug list

• Look up each medicine by name and strength on each plan's list and note its tier. Lower tiers, often generics, usually cost less.
• Look for notes beside the drug, such as prior authorization (the plan must approve it before it pays), step therapy (you must try another medicine first) or a quantity limit.
• Check whether medicines have their own deductible and whether your pharmacy is in network.

Marketplace plans must post a complete, current drug list that anyone can see without logging in. If a medicine you need is not on the list, you, someone acting for you, or your prescriber can ask for an exception. The plan must decide within 72 hours, or within 24 hours in urgent situations, such as when waiting could seriously harm your health. If it says no, you can ask for an outside review. Prior authorization: a patient and physician guide explains approvals and appeals.

Step 5: Compare the rules and extras

• Approvals and referrals: how often the care you expect would need one.
• Care away from home: what the plan covers outside its service area, for example for a student who lives elsewhere part of the year.
• Health savings accounts: beginning in 2026, bronze and catastrophic plans bought as individual coverage through a marketplace count as HSA-compatible. HSA or FSA? How each works explains the accounts.

If you buy your own plan

Dates for 2027 coverage

• HealthCare.gov: open enrollment runs from November 1, 2026, to January 15, 2027. Enroll by December 15 for coverage that starts January 1.
• In California, Covered California's open enrollment runs from November 1, 2026, to January 31, 2027. Enroll by December 31 for coverage that starts January 1, or in January for coverage that starts February 1.
• Some other states run their own marketplaces and may set different dates.

Metal tiers. Marketplace plans are grouped by how they split costs, not by quality. On average, Bronze plans pay about 60 percent of covered costs, Silver about 70 percent, Gold about 80 percent and Platinum about 90 percent. Lower tiers usually mean lower premiums and higher costs when you get care. Catastrophic plans are for people under 30 and some people with a hardship or affordability exemption.

Financial help for 2027

• The larger federal tax credits have ended. The bigger premium tax credits of 2021 through 2025 expired on December 31, 2025. Covered California's July 2026 announcement of 2027 rates confirmed that Congress had not extended them; check your marketplace for any later change. For 2026 and later, the federal premium tax credit is generally available only when household income is between 100 and 400 percent of the federal poverty level. For 2027, what you are expected to pay toward a benchmark Silver plan ranges from 2.15 to 10.22 percent of household income, depending on income.
• Estimate your income carefully. Starting with tax year 2026, if your advance tax credit payments were more than the credit you qualify for, you must repay the full difference with your federal tax return; the earlier repayment caps are gone. Update your application when your income or household changes.
• Silver plans can come with extra savings. If your household income is no more than 250 percent of the federal poverty level, you may qualify for cost-sharing reductions, which lower deductibles, copays and coinsurance. Except for some American Indian and Alaska Native enrollees, you get them only in a Silver plan, and they can make Silver cheaper over a year than a Bronze plan with a lower premium.
• Some immigrants lose help with premiums in 2027. Covered California says a federal law passed in 2025 limits financial help in 2027, among immigrant groups, to lawful permanent residents (green card holders), Cuban and Haitian entrants, and Compact of Free Association migrants. Others, such as people granted asylum, refugees, and people with Temporary Protected Status or work or student visas, lose that help but can keep their coverage. If this may apply to you, ask a certified enroller before you choose.

In California

• Covered California uses standard benefit designs: within a metal tier, the benefits are the same no matter which company you choose. Two Silver plans can still differ in premium, network, drug list and quality ratings, so compare those.
• For 2027, the state put $300 million toward lowering premiums for people with incomes up to 200 percent of the federal poverty level, which Covered California lists as $31,920 a year for one person or $66,000 for a family of four.
• Prices and networks change every year, so re-shop even if you plan to renew. What changes for health coverage in 2027 tracks this year's changes. If you have Medi-Cal or might qualify, see Medi-Cal in plain language.

If you are choosing between job-based plans

• Ask for the SBC for every option. Your employer sets its own enrollment dates.
• Turn paycheck amounts into a yearly premium. Multiply each paycheck's deduction by the paychecks in a year: 26 if you are paid every two weeks, 24 if twice a month.
• Subtract money your employer puts in for you, such as a deposit into an HSA or a health reimbursement arrangement.
• Compare every way to cover your household. If you and a partner both have job-based coverage, also price splitting family members between plans.
• Know when the marketplace is an option. If your job offers coverage that meets minimum standards and your share of the premium for its lowest-cost self-only plan is less than 9.96 percent of household income in 2026, or 10.22 percent in 2027, you cannot get a premium tax credit for your own marketplace plan. For family members, the test uses the cost of covering the whole family. Applying to see your options is free.
• Know when you can change. A job-based plan must give you at least 30 days to enroll after you lose other coverage, marry, have a baby or adopt. Ask your benefits office about other mid-year changes. If you are losing a job, see Lost your job? A checklist for benefits and health coverage.

Medicare is a separate decision

Medicare has its own plans, rules and dates. Its fall open enrollment, October 15 to December 7, is when you can join, switch or drop a Medicare Advantage plan or a Medicare drug plan. Medicare open enrollment for 2027 explains how to compare Medicare plans.

Side-by-side comparison sheet

Where to get free help

• HealthCare.gov Marketplace Call Center: 1-800-318-2596 (TTY 1-855-889-4325), 24 hours a day, every day except holidays.
• In California, Covered California: 1-800-300-1506 (TTY 1-888-889-4500), Monday through Friday, 8 a.m. to 6 p.m. Free in-person help from certified enrollers is available in many languages.
• In California, Health Consumer Alliance: 1-888-804-3536, free help if you have trouble getting or keeping coverage or a problem with your plan.
• Your employer's benefits office, for job-based plans.

Sources

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