Enrichment · Life Skills

Who pays the bill, and when the plan starts paying.

Enter two health plans the way the benefits sheet lists them. Run a light, medium or big year of bills, or your own, and follow each bill as it splits into deductible, coinsurance and what the plan pays.

Run the simulator What you get

The simulator

The worked example compares a copay plan with a high-deductible plan through a big year. Change any plan term or bill and every total and sentence follows.

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What you get

Enrichment · Life SkillsFree

What you finish with: The year's total for two health plans (premiums, your share of the bills, any employer deposit), a bill-by-bill walk-through of the deductible, coinsurance and out-of-pocket maximum, and a chart of where one plan becomes cheaper than the other.
Who it is for: Young adults choosing a first health plan at work or on the Marketplace, families at open enrollment, and the high school and adult-education teachers who teach how insurance works.
Format: Browser tool. Works on a phone or computer. Print or save as PDF, a bill-by-bill .csv, and a file to move your plans between devices.
Access: Free. No account and no sign-in. Plans and bills stay in this browser; nothing is sent to Caveat.
Where it lives: The Life Skills space in Caveat Enrichment.
Support: Questions, a correction or a request: team@caveatacademic.com.

How to use it

Find each plan's Summary of Benefits and Coverage. Copy the premium you pay, the deductible, the coinsurance and the out-of-pocket maximum.
For each service, choose whether the plan charges a copay or makes you meet the deductible first.
Pick a light, medium or big year, or enter the bills you expect under "Your own year".
Step through the bills to see where each dollar goes, then compare the year's totals.
Print the comparison and bring it to open enrollment or your benefits meeting.

Run the simulator

How a bill is split

The usual rules for in-network care on one person's plan, applied one bill at a time in date order.

The rules the simulator follows

Allowed amount: the price the plan has agreed with in-network providers. Every split starts from it, not from the provider's list price.
Preventive care such as a yearly checkup and recommended screenings is covered in full in network, with no deductible.
Deductible: until it is met, you pay the whole allowed amount of services that go through it. Then you pay your coinsurance percentage and the plan pays the rest.
Copay: a flat amount for a visit or prescription. Here copays count toward the out-of-pocket maximum but not the deductible, which is common; some plans differ.
Out-of-pocket maximum: once your deductible, coinsurance and copays reach it, the plan pays 100% of covered in-network care for the rest of the plan year. Premiums never count toward it.

What it leaves out

Out-of-network care, balance bills, services the plan does not cover and prior-authorization denials.
Family coverage, where a plan can have a per-person and a family deductible and maximum. Enter one person's plan terms to see one person's year.
Tax savings: money put into a health savings account (HSA) through payroll is generally not taxed, which can make a high-deductible plan cheaper than shown. Only plans that meet IRS high-deductible rules allow an HSA.
Drug tiers, specialty drugs and plans where coinsurance differs by service. Use the closest rule.

The worked example, checked when the page is built. The copay plan costs $210 a month with a $1,000 deductible, 20% coinsurance and a $4,000 maximum; the high-deductible plan costs $120 a month with a $3,300 deductible, 20% coinsurance, a $7,000 maximum and a $750 employer deposit to a health savings account. In the light year the high-deductible plan comes to $972 against $2,655, and in the medium year $2,505 against $3,300. In the big year, with an emergency visit and surgery, the copay plan wins: $6,520 against $7,690, because its out-of-pocket maximum is $3,000 lower. Plans, prices and bills are made up.

Sources

HealthCare.gov glossary: "Allowed amount", "Deductible", "Coinsurance", "Copayment", "Out-of-pocket maximum/limit" and "Preventive services" (healthcare.gov/glossary).
Centers for Medicare & Medicaid Services, the Summary of Benefits and Coverage and Uniform Glossary required for health plans under the Affordable Care Act, including the coverage examples on every SBC.
HealthCare.gov, "Preventive health services": in-network preventive services covered without a copayment or coinsurance, even before the deductible is met, on Marketplace and most other plans.
Internal Revenue Service, Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans: high-deductible health plan requirements, HSA contributions and their tax treatment.

General information, not insurance, tax or legal advice. The simulator applies common in-network rules to the numbers you enter; your plan's documents decide what you actually owe. The worked example's plans and bills are made up. Support: team@caveatacademic.com.