Cost Sharing
Cost sharing is the portion of covered health care costs that you pay, even after you have health insurance coverage. Cost sharing can include your deductible, copays, and coinsurance, and it affects what you owe when you receive covered care. The main purpose of cost sharing is to split the cost of your care between you and your insurance plan.
Last updated: August, 2026
Key Takeaways
- Cost sharing is what you pay out-of-pocket for covered services when you receive care.
- Deductibles, copays and coinsurance are common types of cost sharing.
- Your cost sharing can be different depending on the service and whether you stay in-network.
- Plans with lower monthly premiums often have higher cost sharing when you get care.
- Understanding cost sharing can help you budget and avoid surprise medical bills.
What is Cost Sharing in Health Insurance?
Cost sharing is how a Marketplace health insurance plan splits health care costs between you and the plan when you get covered services. Instead of paying all of the bill, you usually pay part through a deductible, copay, or coinsurance.
Cost sharing can apply to many types of care, such as doctor visits, prescriptions, tests, and hospital services. The amount you pay may depend on whether you use in-network providers and whether you have met your deductible for the plan year. Knowing your cost sharing helps you know what care may cost before you schedule it.
How This Shows Up in Real Life
Suppose you see an in-network doctor for a sick visit and pay a copay at the appointment. Later, you have an imaging test that requires coinsurance, so you pay a percentage ofthe approved amount after meeting your deductible. Both the copay and coinsurance are types of cost sharing.
The three main types of cost sharing are:
- Deductibles - the amount you pay before your plan starts helping pay for care
- Coinsurance - the percentage of costs you pay after meeting your deductible
- Copayments - the set dollar amount you pay for specific services
How Cost Sharing Affects What You Pay
Cost sharing affects your budget in two ways: what you pay each time you get care and how quickly your costs add up during the year. Higher deductibles can mean higher costs early in the plan year, before your plan starts paying more of the bill. Lower cost sharing can make care more affordable when you need it, but those plans may have higher monthly premiums. Comparing your expected care needs with your plan’s cost sharing details can help you choose coverage that fits your budget.
Where to Find This in Your Plan Details
To understand your cost sharing amounts, you can look at:
- Your Summary of Benefits and Coverage (SBC)
- Your Schedule of Benefits
- Your member handbook or policy documents
- Your health plan’s website, your Ambetter Health online member account, or the mobile app.
These resources can help you find your deductible, copays, coinsurance, and out-of-pocket maximum.
How This Changes Across Marketplace Plans
Cost sharing is different across Marketplace plans, even when plans cover similar services. Differences in plan category, deductibles, and network rules can change how much you pay when you get care.
- Plans with lower monthly premiums often have higher deductibles and cost sharing for services.
- Plans with higher monthly premiums often have lower cost sharing, which makes care costs easier to predict.
- Silver plans may have lower cost sharing for people who qualify for cost sharing reductions.
- Out-of-network rules can affect whether cost sharing applies and how high your costs may be.
In-network rules can be different across Marketplace plans, especially based on network type and how out-of-network care is handled. Understanding these differences can help you pick a plan that matches your provider preferences and budget.
| Plan Tier | Monthly Premium | Typical Cost Sharing |
|---|---|---|
| Bronze | Lower | Higher deductibles and cost sharing |
| Silver | Moderate | Moderate cost sharing (may be lower with CSR) |
| Gold | Higher | Lower deductibles and cost sharing |
FAQs About Cost Sharing
No, your premium is the amount you pay each month to keep your coverage active. Cost sharing is what you pay when you use covered services, like copays, coinsurance, or your deductible.
Not always. Many Marketplace plans cover certain preventive services at no cost to you when you use in-network providers. Other services may still require cost sharing, depending on your plan.
Cost sharing usually includes your deductible, copays, and coinsurance. It can also include what you pay toward your out-of-pocket maximum for covered, in-network services. Your plan details will show which costs apply to different types of care.
Yes, many plans have lower cost sharing when you use in-network providers. Out-of-network care may cost more or may not be covered, depending on the plan.
Yes. Every Marketplace plan has an out-of-pocket maximum. This is the most you'll pay in cost sharing for covered, in-network services in a plan year. Once you reach this limit, your plan pays 100% of covered costs for the rest of the year. Your monthly premium doesn't count toward this maximum.
Some costs don't count as cost sharing and don't apply to your out-of-pocket maximum. These usually include:
- Your monthly premium
- Costs for services not covered by your plan
- Out-of-network care costs (in most plans)
- Balance billing charges
- Costs that go over the plan's allowed amount
For more details, see Allowed Amount and Out-of-Pocket Maximum.
Related Terms
What Is an Out-of-Pocket Maximum?
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What Is Coinsurance in Health Insurance?
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What Is a Deductible in Health Insurance?
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What Is an Allowed Amount in Health Insurance?
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Learn MoreHave questions? Let’s walk through how this works with your plan.
Already covered? Your benefits vary by plan and location. Limitations and exclusions may apply. Contact Ambetter Health or call Member Services at the number on the back of your Member ID Card for answers specific to your coverage.
Not yet a member? Our licensed agents are ready to help you find the perfect plan. Call 855-680-3270 (TTY: 711), Monday-Friday 8 a.m. to 9 p.m. ET, to discuss your health insurance options.
Sources:
Healthcare.gov/glossary - Cost Sharing
Healthychildren.org - Understanding Cost Sharing: Deductibles, Copayments & Coinsurance
Healthreformebeyondthebasics.org - Cost Sharing Charges
Healthpartners.com - Cost-sharing: What it means and why it matters in health insurance