How much health insurance covers depends on your plan’s metal tier and how far into the plan year you are. On average, a Bronze plan pays about 60% of covered medical costs, Silver pays 70%, Gold pays 80%, and Platinum pays 90%, with you covering the rest through deductibles, copays, and coinsurance until you hit your out-of-pocket maximum — after which the plan pays 100% for the remainder of the year.1HealthCare.gov. Plans Categories Those percentages are population averages, not guarantees on any single bill, so the real answer to “how much” is the one printed on your own plan’s documents.
What the Metal Tiers Actually Pay
Marketplace plans are sorted into tiers by actuarial value, which is the estimated share of covered costs the plan picks up for a typical group of enrollees.
- Bronze: about 60% paid by the plan, 40% by you. Lowest premiums, highest deductibles.
- Silver: about 70% / 30%. If your income qualifies you for cost-sharing reductions, a Silver plan can cover 73% to 96% of costs. Cost-sharing reductions are only available on Silver.
- Gold: about 80% / 20%.
- Platinum: about 90% / 10%. Highest premiums, lowest costs when you use care.
The tier changes the split, not the list of services. Every marketplace and small-group plan has to cover the same ten essential health benefits regardless of metal level.2CMS.gov. Essential Health Benefits A Bronze enrollee who needs expensive care can still pay thousands before the plan starts covering a meaningful share.3Health Reform Beyond the Basics. Cost-Sharing Charges in Marketplace Health Insurance Plans
The Four Numbers That Decide Your Share
The split between plan and patient is really controlled by four figures on your plan summary.
- Deductible. What you pay out of pocket each year for covered services before the plan starts sharing costs. Free preventive services don’t count against it. For 2026, the average employer-sponsored single-coverage deductible is around $1,886, while marketplace Bronze plan deductibles run roughly $5,850 to $7,000 and Silver deductibles can reach $8,190 to $9,800.4Healthcare Insider. What Is the Average Health Insurance Deductible in 2026
- Copay. A flat dollar amount at the time of service. Primary care copays typically run $10 to $50; specialist copays average about $45.5Zocdoc. How Much Is a Doctor Visit With Insurance
- Coinsurance. Your percentage of a bill after the deductible is met. At 20% coinsurance on a $1,000 bill, you pay $200 and the plan pays $800.6HealthCare.gov. Coinsurance
- Out-of-pocket maximum. The ceiling on what you can be required to pay for covered, in-network care in a plan year. Once you hit it, the plan pays 100% through year-end. The 2026 federal limit is $10,600 for an individual and $21,200 for a family.7HealthCare.gov. Out-of-Pocket Maximum Limit
Lower premiums almost always mean higher deductibles and coinsurance, so you pay more when you actually use the plan. Higher premiums shift more cost onto the insurer from the first visit forward.8Cigna. Copays, Deductibles, and Coinsurance
What Every ACA Plan Has to Cover
Non-grandfathered individual and small-group plans must cover ten categories of essential health benefits:2CMS.gov. Essential Health Benefits
- Outpatient care
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including dental and vision
On top of that, recommended preventive services are covered at no cost to you when you use an in-network provider, meaning no copay, coinsurance, or deductible applies.9HealthCare.gov. Preventive Care Benefits That includes blood pressure, cholesterol, and diabetes screenings; colorectal cancer screening (ages 45–75); lung cancer screening for heavy smokers and recent quitters (ages 50–80); depression screening; HIV screening and pre-exposure prophylaxis for high-risk patients; flu, hepatitis, HPV, shingles, and tetanus immunizations; tobacco cessation; and alcohol and obesity counseling. Additional no-cost services exist for women (including contraception) and children (including well-child visits).10HealthCare.gov. Preventive Care Benefits for Adults
What Health Insurance Usually Doesn’t Pay For
Every plan has an exclusion list. Commonly excluded categories include:
- Cosmetic procedures that aren’t medically necessary.
- Adult dental and vision care, which generally require separate coverage. Pediatric dental and vision remain part of essential health benefits.
- Fertility treatments like IVF and egg freezing, unless the plan or state law requires them.
- Alternative therapies such as acupuncture, massage, and naturopathy outside a formal care plan.
- Experimental drugs, devices, and procedures.
- Long-term custodial care in a nursing home. Private plans rarely cover it; Medicaid is one of the few programs that does.
Even covered services can go unpaid if your provider skips a required prior authorization. A missed approval often results in a denied claim.11UnitedHealthcare. How to Pay for What Health Insurance Doesn’t Cover Short-term limited-duration plans sit outside this whole framework and are not required to cover essential health benefits; among plans reviewed by KFF, 40% exclude mental health, 48% exclude outpatient drugs, and 98% exclude maternity care.12KFF. Examining Short-Term Limited-Duration Health Plans
How the Split Changes By Service
Emergency Room Visits
ACA plans cannot charge more for an out-of-network ER than an in-network one, and the No Surprises Act has banned balance billing for most emergency services since January 2022, capping your cost-sharing at in-network rates.13CMS.gov. Using Insurance: Know Your Rights You still owe your copay, deductible, and coinsurance. The median allowed amount for an ER visit, per UnitedHealthcare data, is about $1,700, compared to $165 for urgent care and $160 for a primary care visit.5Zocdoc. How Much Is a Doctor Visit With Insurance Ground ambulance services are not currently covered by the No Surprises Act and can still generate out-of-network bills.
Prescription Drugs
Most plans use a tiered formulary. The lowest tier (usually generics) carries the smallest copay; specialty drugs on the top tier carry the highest.14Patient Advocate Foundation. Understanding Drug Tiers If a drug isn’t on the formulary or sits on a high tier, your prescriber can request an exception for medical necessity.15Medicare.gov. How Drug Plans Work Medicare Part D has an annual drug-specific out-of-pocket cap under the Inflation Reduction Act — $2,000 in 2025, rising to $2,100 for 2026 — after which the enrollee pays nothing for covered drugs for the rest of the year.16CMS.gov. Final CY 2026 Part D Redesign Program Instructions ACA marketplace plans don’t have an equivalent drug-only cap; drug costs count toward the general out-of-pocket maximum.
Mental Health and Substance Use Treatment
Behavioral health is one of the ten essential health benefits, so every marketplace plan covers it. The Mental Health Parity and Addiction Equity Act also bars plans from imposing higher copays, stricter visit limits, or heavier prior authorization requirements on behavioral health than on comparable medical and surgical care.17CMS.gov. Mental Health Parity and Addiction Equity A 2024 federal rule tightened enforcement, especially around prior authorization and network adequacy.18U.S. Department of Labor. New MHPAEA Rules: What They Mean for Providers The current federal administration has said it will not prioritize enforcement of those new requirements, and the rule faces legal challenges.19The Commonwealth Fund. Behavioral Health Parity Takes a Step Backward Under Trump Administration Washington, Colorado, Maryland, and Georgia are among the states that have codified the 2024 standards or independently enforced parity obligations.
Hospital Stays and Surgery
Hospitalization is an essential health benefit. After your deductible, you typically pay coinsurance (often 20%) until you hit your out-of-pocket maximum. The underlying bills are large: a one-day stay averaged about $3,025 in 2022, and planned inpatient procedures running two to three days start around $7,000 before insurance.20Debt.org. Hospital and Surgery Costs Your actual share depends on your deductible, your coinsurance rate, and how much you’ve already spent toward your out-of-pocket maximum that year.
Prior Authorization and Denials Cut Into What’s Paid
A service listed as “covered” is not the same as a service the plan will pay for. Prior authorization — advance approval from the insurer — gates a lot of the expensive care your plan technically covers. A 2026 study in JAMA Health Forum found that among branded medications initially flagged for prior authorization, only 54% were ultimately approved. For the 65% of prescriptions not processed on the same day, the median wait was six days.21JAMA Health Forum. Prior Authorization and Associated Delays and Denials of Branded Medication Dispensation
Roughly 20% of marketplace plan claims were denied in 2024. Out-of-network claims were denied at 37%; in-network claims at 19%. Most denials were administrative — duplicates, missing information, plan-design exclusions — rather than medical-necessity decisions.22KFF. Claims Denials and Appeals in ACA Marketplace Plans in 2024 Fewer than 1% of denied in-network claims were appealed, but the American Hospital Association reports that more than half of denied claims are eventually overturned on appeal, though it often takes multiple rounds.23American Hospital Association. Payer Denial Tactics: How to Confront a $20 Billion Problem In June 2025, major U.S. insurers voluntarily agreed to shrink the list of services subject to prior authorization, and a 2024 CMS rule taking effect in January 2027 will require electronic prior authorization portals for Medicare Advantage, Medicaid, and marketplace plans. At least ten states run “gold card” programs that let providers with high approval rates bypass prior authorization for certain services.24The Commonwealth Fund. How Health Insurance Coverage Denials Affect Americans
Surprise Billing Protections
The No Surprises Act bans balance billing in three scenarios where patients historically got stuck with out-of-network charges they couldn’t avoid: emergency services at any facility, non-emergency care from out-of-network providers at in-network facilities (such as an out-of-network anesthesiologist at a scheduled surgery), and out-of-network air ambulance transport.25CMS.gov. No Surprises: Understand Your Rights Against Surprise Medical Bills In those situations your cost-sharing is capped at in-network amounts, and those costs apply toward your in-network out-of-pocket maximum.26U.S. Department of Labor. Avoid Surprise Healthcare Expenses Uninsured and self-pay patients are entitled to a good-faith estimate before care; if the final bill exceeds that estimate by $400 or more, they can start a dispute resolution process.27Consumer Financial Protection Bureau. What Is a Surprise Medical Bill and What Should I Know About the No Surprises Act Suspected violations can be reported to the CMS No Surprises Help Desk at 1-800-985-3059.
How to See What Your Own Plan Covers
Averages only go so far. For the actual numbers on your plan, go to the documents your insurer is required to provide.
- The Summary of Benefits and Coverage (SBC) is a standardized, plain-language document that lists covered services, cost-sharing, and exclusions, and walks through examples like managing diabetes or having a baby.28HealthCare.gov. Summary of Benefits and Coverage
- The formulary lists your plan’s covered drugs by tier. Check it before filling a new prescription.
- Your insurer’s member portal usually shows network status for a given provider, cost estimates, and prior authorization flags.
- Member services, at the number on your card, can confirm whether a specific service is covered and whether prior authorization is required.
The SBC is a summary. For the full exclusions and limitations, the Certificate of Coverage or Evidence of Coverage document is the definitive reference.29UnitedHealthcare. Summary of Benefits and Coverage