Health Plan Cost Comparison | Illustrative Budget

U.S. illustration for one person and a new plan year, with no prior deductible or out-of-pocket spending. Both plans use the same entered other covered in-network allowed charges before cost sharing, not provider bills or amounts already paid. Actual negotiated rates and networks can differ. Office visits are a separate copay-only assumption: the entered copay applies before the deductible, counts toward the shared out-of-pocket cap and does not reduce the deductible. Exclude those visits' full charges from other allowed charges. Use this scenario only if those terms match your actual plan documents. It is not a premium quote, coverage ranking or eligibility determination.

Use this U.S. illustration to compare one person's annual budget under two entered plan assumptions. Both plans use the same amount of other covered in-network allowed charges and the same office-visit count. An allowed charge is the plan's recognized amount before patient cost sharing, not a provider's billed amount or money you have already paid. Actual plans may negotiate different allowed amounts, so a common dollar assumption makes a limited arithmetic comparison. It does not predict a claim. Start at a fresh plan year with no prior deductible or out-of-pocket spending; family accumulators and remaining midyear balances are outside this scenario.

Monthly premiums are multiplied by 12 and stay outside the care-cost cap. Other allowed charges pay the deductible first; the entered patient coinsurance percentage applies to the remainder. Coinsurance rounds once, half up to cents. Office copays are added, then modeled care costs are capped. This aggregate budget does not reproduce claim order or insurer payments. Equal cent totals are a tie; a lower modeled budget does not mean better coverage. One shared deductible and cap must satisfy deductible ≤ cap for this supported scenario. Separate drug deductibles, family rules, prior spending, preventive exemptions, noncovered/out-of-network care, balance bills, tax treatment and assistance are excluded. The entered cap is not a guarantee of maximum total spending.

The monthly premium is multiplied by twelve and always remains outside the entered care-cost cap. Each plan's office-visit copay is multiplied by the whole visit count. Those copays count toward the modeled out-of-pocket limit, but do not satisfy the deductible. Other allowed charges use the deductible first and then the patient's entered coinsurance percentage. Do not include the same office visits in those other charges: their copay treatment has already been represented separately. The illustration combines annual cost-sharing amounts before applying one cap; it does not simulate the order of claims, service-specific exceptions or a provider's actual payment.

Compare the annual total and its premium and patient-care components, rather than treating one number as an enrollment recommendation. Exact equal cent totals produce an explicit tie. A lower modeled annual budget does not mean better coverage, a suitable network, covered prescriptions or a guaranteed saving. Review each plan's Summary of Benefits and Coverage and its complete documents. Check which visits really have copays before the deductible, which charges share accumulators, and whether all entered services are covered in network. Test more than one allowed-charge assumption. If the plans have separate drug deductibles or family limits, this shared-pool model is not the right representation.