How this is calculated
Total yearly cost = annual premium − employer HSA/HRA contribution + your out-of-pocket costs. The x-axis is the allowed amount of care in a year: the price your plan has agreed to pay a provider, before your share is taken out.
- Premium. Your paycheck deduction times the number of paychecks (52, 26, 24 or 12), or the annual amount you enter.
- Network split. The slider sends that share of spending to the in-network rules and the rest to the out-of-network rules. Each network has its own deductible, coinsurance and out-of-pocket maximum.
- Deductible first. You pay every dollar until the deductible is met.
- Then coinsurance. After the deductible you pay your coinsurance percentage. 20% means the plan pays 80%.
- Capped at the out-of-pocket maximum. Once your share reaches the out-of-pocket maximum, the plan pays 100% of covered in-network care for the rest of the year. A blank out-of-network maximum means there is no limit.
- Copays (optional). When you turn on the visit estimate, copays times visits are added as a fixed in-network amount and count toward the in-network out-of-pocket maximum, as the Affordable Care Act requires for in-network essential health benefits. High-deductible plans are treated as having no copays because the deductible usually applies first.
- Employer money. An employer HSA or HRA contribution is subtracted from your cost, as if it pays your first bills. Unused HSA money stays yours, so it still has value.
Each line is made of straight segments, so the break-even points are solved exactly, not read off the picture.
Assumptions and what real plans do differently
- One coverage level. Enter the deductible and maximum for the tier you will pick (self-only or family). Embedded family deductibles, where each person has their own smaller deductible, are not modeled.
- Copays apply outside the deductible. Some plans apply the deductible to specialist or urgent care visits first.
- No separate prescription deductible or drug tiers beyond a single generic copay.
- Balance billing is not included. Out-of-network providers can bill you the difference between their charge and the allowed amount, and that usually does not count toward any maximum.
- Non-covered services (for example, some cosmetic or experimental care) are outside this model.
- HSA tax savings are illustrative. We multiply your own planned contribution by the marginal tax rate you enter. Contribution limits, payroll taxes, state taxes and eligibility rules are not modeled, and the savings are not in the chart lines.
Every plan must publish a Summary of Benefits and Coverage with these numbers in a standard format. HealthCare.gov explains it here: Summary of Benefits and Coverage (SBC), and defines the out-of-pocket maximum.
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Disclaimer: This calculator is for educational purposes only and is not insurance, tax, legal or medical advice. The preset plans use example numbers, not real plan data. Your costs depend on your plan's actual terms, your providers and the care you receive. Review your plan's Summary of Benefits and Coverage and talk with your benefits administrator or a licensed professional before making decisions.