Free tool · runs in your browser
Health Plan OOP Comparison
Enter each plan's annual premium and out-of-pocket maximum plus your expected annual medical spending to see which plan wins at low use, expected use and catastrophic use.
Inputs
Results
How the plan comparison works
- Cost model: total annual cost = annual premium + min(your medical spending, the plan's out-of-pocket maximum). The out-of-pocket maximum is the legal yearly cap on what you pay in-network cost-sharing, so a year that goes badly approaches premium + cap — the worst case every plan comparison should demonstrate.
- Crossover spending: the curves are piecewise-linear. If the higher-premium plan has the lower cap, there is a spending level at which the plans cost the same. Below it the cheaper-premium plan wins; above it the lower-cap plan wins.
- This is plan comparison, not OOP math: the single-plan question "when do I hit my out-of-pocket maximum, and what has cost me relative to it" is a different tool. That math lives on Recovery Numbers' out-of-pocket max calculator.
- Simplifications: deductible/coinsurance composition inside the cap isn't modeled, and out-of-network claims aren't counted at all (they don't in most plans generate a shared cap). Windfall uses underestimate the mid-segment slope for high-deductible plans.
Worked example
Plan A: $6,000/year premium, $4,000 out-of-pocket max. Plan B: $2,400/year premium, $8,000 out-of-pocket max. At $2,000 of expected spending: Plan A total = $8,000; Plan B = $4,400 — Plan B wins by $3,600.
Catastrophic year: Plan A tops out at $10,000 ($6,000 + $4,000); Plan B at $10,400 ($2,400 + $8,000). Crossover level: $6,000 + $4,000 − $2,400 = $7,600 of expected spending — expect more than that and Plan A ends up cheaper.
Choosing between a high-premium/low-cap plan and its mirror
Three check points beyond the totals:
- Regular prescriptions: count them as part of medical spending under the cap — monthly specialty drugs effectively push you near the OOP max every year regardless.
- HSA eligibility: HDHPs (high-deductible, high-cap plans) pair with HSA cash, which changes the funding flows but not the sum of costs.
- Network: the calculator assumes in-network care; if a planned-use provider is out of network on one plan, that plan's projected totals change more than these numbers show.
Frequently asked questions
What is an out-of-pocket maximum?
The most you pay for covered in-network care in a plan year: deductibles, coinsurance and copays for covered services all count toward it. Premiums do not. After the cap, the plan pays 100% of covered in-network services. (See Healthcare.gov's glossary entry on out-of-pocket maximums.)
Does the comparison include copays?
We do not model copay tile-by-tile — copays and coinsurance at typical usage land well below the cap for low-use membership, and below the cap for catastrophic ones too. The low/expected/high scenery above brackets the honest outcome without modeling details the plan's Summary of Benefits specifies.
What about tax deductions or employer contributions?
Not included. Use each plan's actual employee-share premium (the contribution you pay per paycheck × pay periods) rather than the plan's sticker rate; employer contributions differ per plan and materialize into real cost differences.
Is this advice for choosing a plan?
No — it is math on the two published numbers that most reliably differ (premium and out-of-pocket max). Read the Summary of Benefits for network composition and prescription tiers before deciding; costs estimates are estimates only.
Estimates last reviewed . Results are estimates for educational use; not insurance advice. Methodology →