What is on the health insurance comparison worksheet
- Premium
- What you pay every month whether or not you use the plan. On an employer plan, your share after the employer's contribution. Multiply by 12 to compare with the deductible honestly.
- Deductible
- What you pay for covered care before the plan starts paying (except services with a flat copay, and preventive care, which is free on ACA-compliant plans). Individual and family amounts both matter.
- Out-of-pocket maximum
- The most you can pay in a year for covered in-network care, premiums excluded. After this the plan pays 100%. It is the number that tells you your worst case.
- Copay and coinsurance
- A copay is a flat fee per visit or prescription; coinsurance is a percentage of the bill after the deductible. Plans mix them.
- Drug tiers
- Generic, preferred brand, non-preferred brand, specialty. The same drug can be tier 1 on one plan and tier 3 on another; the formulary says which.
- HSA, HRA, FSA
- High-deductible plans pair with a Health Savings Account, often with employer money in it; that money offsets the deductible and rolls over. FSAs are use-it-or-lose-it.
- Network and referrals
- HMOs usually require a primary care doctor and referrals and cover nothing out of network; PPOs cost more and let you go anywhere at a higher share; EPOs are in between.
- Expected care costs
- Your best estimate of the year's visits, prescriptions and procedures at typical charges. The estimator turns it into a total per plan.
Why the lowest premium is often not the cheapest plan
Total cost for a year is premium × 12 plus what you pay for care, and what you pay for care depends on the deductible, coinsurance and out-of-pocket maximum. A plan with a $310 premium and a $6,600 family deductible costs $3,720 before any care; a plan with a $690 premium and a $1,500 deductible costs $8,280 before any care. If the family expects $4,000 of care, the first plan ends up around $7,700 before any employer HSA money is counted, and the second around $10,300. If someone needs surgery, both hit their out-of-pocket maximums and the comparison flips toward the plan with the lower maximum. The estimator sheet runs both cases so you choose knowing the range, not just the monthly number.
Open enrollment for employer plans usually runs in October and November; the federal marketplace (HealthCare.gov) runs 1 November to 15 January in most states, with 15 December the deadline for 1 January coverage; Medicare's window is 15 October to 7 December. Outside those windows you can only change plans after a qualifying life event, so the comparison is worth an evening once a year.
Which sheet to use
- Three plans line by line: fill from each plan's Summary of Benefits and Coverage (SBC), the standard document every plan must provide. Rows match the SBC order.
- Cost estimator: build your expected year in the care table, then enter each plan's numbers; Excel calculates typical and worst-case totals.
- Network check: before deciding, confirm every doctor and prescription. Fifteen minutes of phone calls that prevent the most expensive mistake.
How to compare plans
- Get the SBC for each plan (employer portal, HealthCare.gov plan details, or the insurer). It has every number the first sheet asks for in the same order.
- Fill the comparison sheet. Write amounts, not "see plan".
- List last year's care and anything planned for next year in the estimator's care table. Use the plan's own copays where they apply.
- Enter premium, deductible, coinsurance, out-of-pocket max and any employer HSA money per plan. Read the typical and worst-case totals.
- Run the network check for every doctor and every prescription. Call the offices; online directories are frequently wrong.
- Decide, write the reason in the box, and enrol before the deadline.
Mistakes people make at open enrollment
- Choosing on premium alone, or on deductible alone.
- Ignoring the employer HSA contribution, which can be worth more than the premium difference.
- Assuming the doctor is in network because they were last year. Networks change every January.
- Not checking the formulary for a brand-name drug, which can move from $40 to $300 between plans.
- Confusing the individual and family deductible; on many plans one person must meet the individual amount before the plan pays for them, even on a family policy (embedded vs aggregate deductibles; the SBC says which).
- Letting the plan auto-renew without looking.
Where the numbers come from
Every ACA-compliant plan must publish a Summary of Benefits and Coverage in a standard format, including two coverage examples (having a baby, managing type 2 diabetes) that show total out-of-pocket costs; they are a useful sanity check against the estimator. HealthCare.gov and most state marketplaces also show an estimated yearly cost if you enter expected usage. For employer plans, HR can provide the SBCs and the employer HSA or HRA contribution. Dental and vision are usually separate plans; compare them on their own, and use the medication schedule as the source list for the prescriptions row.
Editing the Word and Excel versions
The Excel estimator calculates annual premiums, yearly care costs from the care table, the typical-year total per plan (premiums plus the lesser of the out-of-pocket maximum and deductible-plus-coinsurance, minus HSA money) and the worst-case total. Change the row labels on the comparison sheet to match your SBC if your plans use different terms. In Word, the comparison is a plain table with a wide feature column for notes. Keep this year's sheets; next year's comparison starts from them.
Questions
What is the difference between a deductible and an out-of-pocket maximum?
The deductible is what you pay before the plan starts sharing costs. The out-of-pocket maximum is the most you pay in a year in total (deductible, copays and coinsurance combined); after that the plan pays everything in network. Premiums do not count toward either.
Is a high-deductible plan a good idea?
Often, if you are reasonably healthy, can cover the deductible from savings or an HSA, and the employer contributes to the HSA. The estimator shows your own numbers; if the worst-case total is close across plans, the lower premium plan usually wins.
What is an SBC?
The Summary of Benefits and Coverage, a standard document every health plan must provide, with deductible, out-of-pocket maximum, copays and coverage examples in the same format for every plan. It is the source for the comparison sheet.
When is open enrollment?
Employer plans: usually October to November, set by the employer. HealthCare.gov: 1 November to 15 January in most states (15 December for coverage starting 1 January). Medicare: 15 October to 7 December. Some state marketplaces differ.
Does the PDF calculate the totals?
No. The fillable PDF is for completing and printing. The Excel estimator calculates annual premiums, care costs and the typical and worst-case totals for each plan.
