What Will It Really Cost You?

A Free Calculator to Compare Health Insurance Plans from your Marketplace or Employer

What’s your exposure? With so many variables, comparing health insurance plans can be really hard. What will they pay and what will they cost when you actually use them?

This calculator’s especially good at helping you rule out the bad deals and focus on the better ones. Enter premiums (after subsidies) and other values for the plans you’re considering, then roll over the lines in the graph to see your total outlays.

An example of how to use this: Why would anyone buy the purple plan here for an extra thousand dollars a year, instead of the green plan, which offers the same or better financial protection? Turn off the blue and orange checkboxes to see that comparison clearly, and zoom the X axis to get a close-up look at how more-typical healthy years will play out.

A note on zero-percent coinsurance. If you enter zero for the coinsurance percentage (the share you pay after you’ve spent the deductible limit, until you hit the out-of-pocket limit), the graph will show you never paying more than the deductible — never getting to the OOP. But some things in your plan probably aren’t 0% coinsurance. You will pay more, even after your deductible. So: If your plan has 0% coinsurance, still, enter some percentage — 10% or whatever — in this field to see your actual annual out-of-pocket exposure on the graph.

Things to Consider When Using This App

Copays and coinsurance. Best bet is to enter the plan’s coinsurance percentage for hospitalization, since that is your greatest financial exposure.

Many plans have fixed (generally low) co-pay amounts instead of percentage “co-insurance” for many services, even before you reach your deductible. There’s no way to display that without you entering how many visits, lab tests, etc. you might have. (Gets way too complicated.) Enter your plan’s percent coinsurance, and figure your outlays will be somewhat lower than what you see above because of the low fixed copays for office visits etc.

Extra deductibles and copays. Your total outlays shown above do not include additional amounts you might spend due to some plans’ extra copays and deductibles for emergency/urgent care, doctor visits, drugs, etc.

Most plans don’t have these extras, they vary a lot between plans, and are usually small when they do exist. But sometimes they’re quite significant. If a plan has high exceptions like this, they could significantly increase your spending beyond what you see above (the relative significance would be higher in “normal,” relatively healthy years shown in the lower-left of the graph). In most cases these extra charges count towards your annual out-of-pocket limit, so they don’t affect the “worst case” (upper-right) outlay scenario. But check each plan carefully for these kind of “gotchas.”

Out-of-network spending. If you expect to get all your care from in-network providers (“preferred” providers who are contracted with your insurer), you can skip entering out-of-network information, and ignore the out-of-network lines on the graph.

Out-of-network spending is mostly significant in worst-case situations — some special injury or illness for which you need a specialized clinic or doctor that is not in your insurer’s network. (i.e. You need to fly to the Mayo Clinic or some such for a special cancer treatment.)

Traditionally, out-of-network charges have been more of an issue for rural dwellers who might need to travel to get care, but insurers are paring their networks severely these days, even in urban centers.

Some plans have no out-of-pocket limit on out-of-network payments: In some you’re responsible for unlimited percentage copays, while in others (Exclusive Provider Organizations or EPOs, and many perhaps most HMOs) there’s no out-of-network coverage at all; you pay for everything. These plans will usually save you money on premiums; you have to decide whether that savings is worth the (perhaps unlikely) risk of needing an out-of-network provider. The risks: 1. You’ll have to pay for the provider; 2. You’ll have to decide whether to pay for the provider.

National and multi-state provider networks. Some insurance plans are contracted with large national networks of providers, so you can pay in-network even for providers in other cities and regions. (Most plans do cover out-of-state emergencies.) Others offer in-network coverage in two states at once for people who have two residences. This may be important, for instance, for families in which one member is out of state — a child at college, for instance.

Family vs. Individual. Most family plans have individual and family deductibles and out-of-pocket limits. (Family is often twice the individual amount.) This can make it hard to evaluate your exposure and compare plans. To best judge your worst-case financial exposure — what happens if two of you get really sick — enter the family deductible and OOP amounts in the calculator rather than the individual amounts. This worst-case two-illness scenario is less likely to occur, of course, but the financial hit can be serious if it does.

Drug Costs. Some plans just include drug spending in the normal deductible, copay, and out-of-pocket totals. But different plans’ drug provisions vary wildly. As with normal coverage, watch out for big upside gotchas that could result in a bad financial hit if you need expensive drugs for a long period. Some plans only cover generic drugs (which tend to be cheap in any case so why not just pay for them yourself?), but don’t cover more expensive (often wildly more expensive) brand-name drugs that you may need.

Uncovered spending. Some things just aren’t covered. Read your plan’s Benefit Summary carefully to judge your exposure if you think you might feel the need for those services.

Read the limitations and exclusions. These are usually not included on the Summary of Benefits; you have to ask for them specifically. For instance, some plans don’t cover injuries incurred when you’re intoxicated or high — or your child is. (This exclusion is illegal in many states.) This could result in some very nasty financial surprises, if they decide to enforce these provisions when a big bill comes in.

Bottom Line. Insurers don’t sell you insurance because they’re losing money on it. As in casinos (you are placing a bet here), the house always takes a cut. Rolling over the left side of the graph, you’ll see that in healthy years you spend more than you would if you just paid for health care yourself. (Though you wouldn’t have the insurer’s bargaining power/network price markdowns working for you.) That’s the cost of protecting yourself against worst-case years.

So if you buy “cadillac” plans that pay for everything (and pay the high premiums that go with those plans), your insurer takes a cut on everything. Over the course of your life, the odds are you’ll spend more in total premiums plus out-of-pocket costs.

The lesson: buy the lowest-premium insurance you can find that protects you from spending levels that could significantly damage your savings, your life, and your lifestyle. You have to decide whether the savings on premiums during healthy years (and the additional personal savings you can but might not sock away as a result) make a low-cost plan sensible and worthwhile.

Ah but there are always more exceptions, aren’t there? Here are two:

• There’s another advantage to more-expensive pay-everything plans: you know more accurately how much you’ll spend each year. You pay extra for that certainty. That may be worth it to you.

• Under the ACA provisions, insurers can’t charge you more in premiums because you have a pre-existing condition. If you know that you’ll have significant health expenses in coming years, a higher-premium pay-everything plan may result in lower total outlays for you. If you buy a cheap plan with high deductible and OOP limits, you might get hit hard in one year, but if those charges are going to continue, you’ll be able to shift to a pay-everything plan in ensuing years. The graph above can help you judge those tradeoffs.

Hot tip: If you’re shopping for an individual plan and your income’s low enough that you’re eligible for a subsidy, check out the silver plans. There’s an additional, hidden “Cost Savings Reduction” subsidy for those plans. It doesn’t show as a reduced premium; rather, you pay the same premium as higher-income people do, but get a lower deductible and/or out-of-pocket limit based on your income level. It’s a deal. There’s significant savings to be had here.

Finally: Best wishes for a healthy and prosperous life for you and your family!

To download the data behind the graph: 

When you enter values, the app builds a data table and graphs it. If you’d like to mess with the data in a spreadsheet or some such, or just save it for later, here’s how:

1. Click the Data Table tab at the top.

2. Click the arrow icon at the bottom of the data table and choose Data from the popup menu.

3. Click “Download all rows as a text file.”

About me and this page: 

This page was created by me, Steve Roth. I built a spreadsheet to do this analysis for myself years ago, and then hired a very talented fellow to build it out into this web app. Full disclosure: if this page attracts a decent amount of traffic, I’m hoping to post some ads and make some money. But to that end, I’ve just tried to provide the most useful app and information I can.

The information and analysis on this site is provided free to anyone on the internet who stumbles across it. You should evaluate it with the same care that you would any internet (or other) information. While great effort has been expended to make the information and arithmetic here accurate and useful, there is no warranty or guarantee, implicit or explicit. This page and this app are not the work of an insurance or health-care professional. It’s not professional advice, and you are solely responsible for reviewing and using it with care and judgment.

Comments and questions are welcome! Write me at: info at health-plan-compare dot com.