Quick answer
It depends on the plan. Marketplace plans are sorted by how much of the average person’s costs they pay: about 60% for bronze, 70% for silver, 80% for gold and 90% for platinum. You pay the rest through your deductible, copays and coinsurance, up to a yearly out-of-pocket maximum of $10,600 for one person in 2026 ($12,000 in 2027). After that, the plan pays 100% of covered, in-network care.
Key takeaways
- ACA plans must cover 10 essential health benefits, and preventive care is free.
- There are no annual or lifetime dollar limits on essential health benefits.
- The out-of-pocket maximum caps what you pay in a year for covered, in-network care.
- Adult dental and vision, cosmetic procedures and long-term care usually aren’t covered.
- Job-based plans must pay at least 60% of average costs to meet federal minimum value rules.
On this page
How much each plan level pays
| Plan level | Plan pays on average | You pay on average |
|---|---|---|
| Bronze | 60% | 40% |
| Silver | 70% | 30% |
| Silver with cost-sharing reductions (income up to 250% of poverty level) | 73% to 94% | 6% to 27% |
| Gold | 80% | 20% |
| Platinum | 90% | 10% |
More on the levels in bronze, silver, gold and platinum plans. If you’re not sure which level fits, see how to determine what level of coverage you need.
What ACA plans have to cover
Marketplace and other individual and small-group plans must cover 10 essential health benefits:
- Outpatient care, like doctor visits
- Emergency services
- Hospitalization, including surgery
- Pregnancy, maternity and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Lab services, like blood tests
- Preventive care, including vaccines, and chronic disease management
- Pediatric services, including dental and vision care for children
Coverage for imaging like an MRI falls under these benefits, though your plan may require prior approval.
What you pay before the plan pays
- Deductible: what you pay for covered care before the plan shares costs. See how to meet your deductible.
- Copays: flat fees for visits or prescriptions.
- Coinsurance: your percentage of the bill after the deductible.
- Out-of-pocket maximum: the most you pay in a year for covered, in-network care.
Here’s how that plays out. Say your plan has a $5,000 deductible, 30% coinsurance and a $9,000 out-of-pocket maximum, and you have a $30,000 hospital stay. You’d pay the $5,000 deductible, then 30% of the remaining $25,000, which would be $7,500, but the out-of-pocket maximum caps your total at $9,000. The plan pays the other $21,000. The average deductible for 2026 marketplace plans was $3,786, according to KFF.
What health insurance usually doesn’t cover
- Adult dental and vision care, unless you buy separate coverage.
- Cosmetic procedures.
- Long-term care, like a nursing home stay for help with daily activities.
- Most care outside the U.S.
- Services from out-of-network providers on HMO and EPO plans, except emergencies.
- Some drugs, like many weight-loss medications, depending on the plan.
Plans that aren’t ACA coverage, like short-term plans, can leave out whole categories of care. See health insurance coverage types.
Job-based coverage
Employer plans must cover preventive care and can’t have annual or lifetime limits on essential health benefits. Large employers don’t have to cover every essential health benefit, but most do, and a plan must pay at least 60% of average costs to meet minimum value. Employers also pay most of the premium: about 84% for single coverage and about three-quarters for family coverage in 2025, according to KFF. See is it cheaper to get health insurance through your employer.
How to find out what your plan covers
- Summary of Benefits and Coverage (SBC): a standard, easy-to-compare summary every plan must provide.
- Plan documents: the full list of covered services and exclusions.
- Drug list (formulary): which prescriptions are covered and at what cost.
- Provider directory: which doctors are in network. See how to find out if a doctor is covered.
After you get care, your explanation of benefits shows what the plan actually paid.
Why coverage matters
Without insurance, you pay full price, and one hospital stay can cost tens of thousands of dollars. See the worst that can happen if you get sick without health insurance and what if you can afford your medical bills out of pocket.
Compare how much coverage you can get for your budget: see quotes by ZIP code.
Frequently asked questions
Does health insurance pay 100% of costs?
Only after you reach your out-of-pocket maximum, and for preventive care. Until then, you share costs through your deductible, copays and coinsurance.
Is there a limit on how much my insurance will pay?
Not for essential health benefits on ACA-compliant plans. Annual and lifetime dollar limits on those benefits are banned.
Do premiums count toward the out-of-pocket maximum?
No. The out-of-pocket maximum only counts what you pay for covered care.
Does health insurance cover dental and vision?
For children, yes on ACA plans. For adults, usually not unless you buy separate dental or vision coverage.
Sources
- HealthCare.gov: What Marketplace health insurance plans cover
- HealthCare.gov: Health plan categories
- HealthCare.gov: Out-of-pocket maximum/limit (glossary)
- HealthCare.gov: Summary of Benefits and Coverage (glossary)
- KFF: 2025 Employer Health Benefits Survey
- KFF: What we know about 2026 ACA marketplace enrollment, premiums and deductibles
This article is general information, not insurance advice. Coverage varies by plan and state, so check your plan documents. Last reviewed September 2026.