Question 1

Does this simulator use the provider's billed charge or the insurance plan's allowed amount?

Accepted Answer

It should use the plan's allowed in-network amount. Deductible and coinsurance calculations are generally based on the amount recognized under the plan, not an arbitrary provider charge. The simulator treats your entered amount as that allowed amount.

Question 2

Does this simulator include copays or amounts I already paid earlier in the year?

Accepted Answer

No. This is a simplified single-claim model. It assumes no prior deductible or out-of-pocket spending and does not model copays, premiums, non-covered services, out-of-network costs, or balance billing.

Question 3

What is the difference between a Copay and Coinsurance?

Accepted Answer

A copay is a fixed dollar fee (e.g., $30 per doctor visit), whereas coinsurance is a percentage split (e.g., 20% of total approved charges) paid after meeting your annual deductible.

Question 4

How does an HSA work with a High Deductible Health Plan (HDHP)?

Accepted Answer

For 2026, the HSA contribution limit is $4,400 for self-only HDHP coverage and $8,750 for family HDHP coverage. Contributions may receive favorable federal tax treatment, and distributions used for qualified medical expenses are generally tax-free. Unused HSA balances generally roll over from year to year.

Question 5

What is an Out-of-Pocket Maximum (OOP Max)?

Accepted Answer

The out-of-pocket maximum is the most you generally pay during a plan year for covered in-network services after accounting for applicable deductibles, copayments, and coinsurance. Once you reach it, the plan generally pays 100% of covered in-network benefits for the rest of the plan year. Premiums, non-covered services, most out-of-network costs, and amounts above the allowed amount are not included.

Question 6

What is the difference between an HMO, PPO, and EPO plan?

Accepted Answer

HMO plans generally emphasize in-network care and may require specialist referrals, depending on the plan. PPO plans generally allow out-of-network care at higher cost and usually do not require specialist referrals. EPO plans generally cover only in-network care except for emergencies and generally do not require specialist referrals. Exact rules depend on the plan.

Question 7

What is an In-Network Provider vs Out-of-Network Provider?

Accepted Answer

In-Network providers have contracted with your insurance company to accept pre-negotiated discounted rates. Out-of-network providers have no contract, meaning you pay significantly higher out-of-pocket costs.

Question 8

What is an Explanation of Benefits (EOB)?

Accepted Answer

An Explanation of Benefits (EOB) is a statement from the health plan showing information such as the provider's billed amount, the allowed amount, what the plan paid, and what the member may owe under the plan. An EOB is generally not a bill; the provider may send a separate bill for the member's responsibility.

Health Insurance Cost Simulator (2026)

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