Almost everyone chooses a health plan by comparing monthly premiums. It is the number printed largest, it is the only one that is definitely charged, and it is the number that tells you least about what happens in a year when something goes wrong.
The premium buys you access. Four separate numbers decide what that access costs once you use it, and they fire in a fixed order. This is what each one does, what the federal ceiling for 2027 actually caps, and the three exclusions that catch people who assumed the ceiling was a ceiling.
All of this applies to the United States, and specifically to ACA-compliant coverage — which includes Marketplace plans and most employer plans, but not short-term or fixed-indemnity products sold outside those rules.
The four numbers, in the order they fire
Premium. A fixed monthly charge for holding the policy. Paid whether you see a doctor or not, and — this is the part that surprises people — it does not count toward any of the limits below.
Deductible. What you pay yourself before the plan starts sharing covered costs. Some services, such as preventive care, are typically covered before you meet it.
Coinsurance and copayments. After the deductible, cost is split. Coinsurance is a percentage of the bill; a copayment is a flat amount per visit or prescription. You are still paying, just less of it.
Out-of-pocket maximum. The ceiling. Once your qualifying spending reaches it, the plan pays 100% of covered in-network care for the rest of the plan year.
The last number is the one that describes your worst realistic year, which is precisely what insurance exists to bound. It deserves more attention than the premium and usually gets less.
The 2027 ceiling: $12,000 and $24,000
The federal limit is not set by your insurer. It is published annually by CMS, and for the 2027 benefit year the maximum annual limitation on cost sharing (opens in a new tab) is $12,000 for self-only coverage and $24,000 for other than self-only coverage.
CMS states that this is approximately a 13.2% increase from the 2026 parameters of $10,600 and $21,200.
| Benefit year | Self-only | Other than self-only |
|---|---|---|
| 2026 | $10,600 | $21,200 |
| 2027 | $12,000 | $24,000 |
Those are ceilings, not the figures on your plan. An insurer may set a lower maximum and many do; none may set a higher one.
The indexing is mechanical rather than negotiated. Under 45 CFR 156.130 (opens in a new tab), the 2014 limit is multiplied by a premium adjustment percentage reflecting how far average per-capita private health insurance premiums have moved since 2013. For 2027 that multiplier is 1.8916224814 — which CMS describes as an increase of roughly 89.2% between 2013 and 2026. The family limit is defined as exactly twice the self-only limit, and any increase that does not land on a multiple of $50 is rounded down.
That 89.2% figure is worth sitting with. The consumer protection has kept pace with premium growth by design, which means the maximum exposure a compliant plan may impose has nearly doubled in a little over a decade.
Three things the ceiling does not cap
This is where the word "maximum" does more work than it should. The regulations define cost sharing (opens in a new tab) as expenditure required of an enrollee for essential health benefits — deductibles, coinsurance, copayments and similar charges — and then explicitly excludes three things.
Premiums. They are not cost sharing and never count. Hitting your out-of-pocket maximum does not stop the monthly charge; you keep paying it for the rest of the year.
Balance billing by non-network providers. Where an out-of-network provider bills you for the difference between their charge and what the plan allows, that difference is excluded from the definition entirely.
Spending on non-covered services. If the plan does not cover it, paying for it does not move you toward the ceiling, however medically necessary it felt.
There is a fourth gap in the same regulation. Under §156.130(c), for a plan using a provider network, cost sharing for benefits received outside that network is not required to count toward the annual limitation at all. Many plans operate a separate, much higher out-of-network maximum, or none.
Metal tiers describe a model, not your bill
Marketplace plans are labelled bronze, silver, gold and platinum. Those names are set by 45 CFR 156.140 (opens in a new tab) according to a plan's actuarial value:
| Tier | Actuarial value |
|---|---|
| Bronze | 60% |
| Silver | 70% |
| Gold | 80% |
| Platinum | 90% |
Plans may vary from those figures by −4 or +2 percentage points, with a wider +5 allowance for certain bronze plans — including those structured as high-deductible health plans.
The critical misreading: a silver plan at 70% actuarial value does not mean you pay 30% of your own medical bills. Actuarial value is calculated against a standard modelled population, so it describes how the plan performs across a large group in aggregate. Your individual share depends entirely on what care you actually use. A healthy year on a bronze plan can cost far less than 40% of anything; a bad year will drive you to the ceiling regardless of the tier.
The tier is best read as a trade-off dial between premium and cost sharing, not as a quality rating. A bronze plan structured as a high-deductible health plan may also open access to a health savings account — the 2026 HSA contribution limits set out what that is worth and who qualifies.
The silver rule that costs people thousands
If your household income is at or below 250% of the federal poverty line, there is a second subsidy beyond premium help — and a rule attached to it that is easy to lose money on.
Cost-sharing reductions lower your deductible, copayments and out-of-pocket maximum rather than your premium. For 2027, CMS sets the reduced maximums at:
| Household income | Reduced out-of-pocket maximum (self-only) | Silver plan actuarial value |
|---|---|---|
| 100%–150% FPL | $4,000 | 94% |
| Over 150%–200% FPL | $4,000 | 87% |
| Over 200%–250% FPL | $9,600 | 73% |
Compare the top row with the standard $12,000. For an eligible household, that is an $8,000 difference in worst-case exposure.
Now the rule. Under 45 CFR 155.305(g) (opens in a new tab), these reductions attach only to a silver-level plan. Enrol in bronze, gold or platinum and you cannot receive them, whatever your income. The reduced-cost versions exist as variations of the standard silver plan, which issuers must file alongside it under 45 CFR 156.420 (opens in a new tab). Members of federally recognised tribes are handled separately, through their own zero and limited cost-sharing plan variations.
So an eligible household that picks bronze because the premium is lower forfeits the cost-sharing reductions completely. A silver plan with a 94% actuarial value is more generous than any platinum plan on the exchange, and it is invisible to anyone comparing on premium alone. If you are near or below 250% FPL, price the silver plans before anything else.
Premium tax credits, and the number to check
Premium tax credits reduce the monthly premium rather than the cost sharing. The IRS sets out the eligibility conditions (opens in a new tab): household income within a certain range, Marketplace coverage, not filing as married filing separately except in limited cases, not claimable as someone's dependent, and no access to affordable employer coverage or to Medicare or Medicaid.
Under the standard statutory rule, a taxpayer with household income above 400% of the federal poverty line cannot qualify. The IRS notes that the American Rescue Plan Act temporarily removed that rule for tax years 2021 and 2022.
That temporary treatment is the single most volatile element on this page. It has been legislated and re-legislated, and what applies to one plan year cannot be assumed for the next. Do not plan around a subsidy figure you read anywhere, including here. Run your own application on the Marketplace for the specific year you are buying: it prices your actual household against the rules in force, which no article can do.
The enrollment calendar
For 2027 coverage, HealthCare.gov (opens in a new tab) sets these dates:
| Date | What happens |
|---|---|
| 1 November | Open Enrollment starts — first day to enrol, renew or change plans |
| 15 December | Last day to enrol or change for coverage starting 1 January |
| 1 January | Coverage begins for those enrolled by 15 December who have paid |
| 15 January | Open Enrollment ends |
| 1 February | Coverage begins for those who enrolled 16 December to 15 January |
Outside those dates you need a Special Enrollment Period, which requires a qualifying life event — moving, losing other coverage, marriage, a birth. Medicaid and CHIP applications are accepted at any time.
Some state-run exchanges use different dates, so confirm with your own state's marketplace rather than assuming the federal calendar. If you are approaching 65, the Medicare enrolment rules are separate and run on their own timetable — the 2026 Medicare costs guide covers what those premiums look like.
How to compare two plans without guessing
Premium comparison alone is not analysis. A method that takes fifteen minutes:
- Annualise the premium. Twelve months of it. This is your floor — the amount you pay in a year where you use nothing.
- Add the out-of-pocket maximum. Floor plus ceiling is your worst realistic year for in-network covered care. Compare that total across plans, not the premium.
- Model your actual year. Take last year's care — prescriptions, visits, any recurring treatment — and price it under each plan's deductible and copay structure. Most people are neither the healthy case nor the catastrophic one.
- Check the drug formulary first if you take anything regularly. A drug on a different tier, or absent entirely, will outweigh every premium difference. Non-covered spending does not count toward the ceiling.
- Check the network against the doctors and hospital you actually use. Then check it again for the specific clinicians, not just the facility.
- If you are under 250% FPL, price silver first, for the reason above.
- Confirm whether it is an HSA-eligible high-deductible plan, if that matters to you.
Steps 4 and 5 are where the real money is, and they are the two everyone skips because they are tedious rather than difficult.
None of this requires predicting what happens to health policy. It requires reading your own plan documents against the published limits — which is a smaller job than it looks, and the only version of this anyone can do for you is the one you do yourself.
Sources
- CMS — Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2027 Benefit Year (29 January 2026) (opens in a new tab)
- 45 CFR 155.20 — Definitions (opens in a new tab)
- 45 CFR 155.305(g) — Eligibility for cost-sharing reductions (opens in a new tab)
- 45 CFR 156.130 — Cost-sharing requirements (opens in a new tab)
- 45 CFR 156.140 — Levels of coverage (opens in a new tab)
- 45 CFR 156.420 — Plan variations (opens in a new tab)
- IRS — The Premium Tax Credit: the basics (opens in a new tab)
- HealthCare.gov — Dates and deadlines (opens in a new tab)
This article is general information for a United States audience. It is not financial, tax, legal or insurance advice, and it does not recommend any plan or insurer. Federal cost-sharing limits are published annually and subsidy rules have changed repeatedly between plan years; your own plan documents, your state's marketplace and your Marketplace application govern what you will actually pay. Confirm your position before enrolling, and consider advice from a licensed professional or a free Marketplace navigator. Last reviewed 10 September 2026.
