Groundwater flow models are increasingly considered for the regional scale simulation of hydraulic heads and water table elevation. In the most complete configuration, models explicitly simulate two-way interactions between surface water (SW) and groundwater (GW) to reproduce and forecast both SW and GW water levels. In most regional scale groundwater models, however, SW-GW interactions are represented by simplified boundary conditions that only allow one-way interaction from SW to GW, neglecting most of the dynamic exchange fluxes between SW and GW. To evaluate the potential consequences of such simplifications on the simulation of regional GW levels, we compare two models on a 36,900 km² regional aquifer system in Southern Quebec. One model explicitly simulates both SW and GW flow with two-way SW-GW feedback and the other model only simulates GW flow with a surface boundary flux to represent a one-way interaction with the land surface. Both models are developed with the same numerical code to ensure that the only differences are the representation of SW water flow and SW-GW feedback. The one-way model simulates overall deeper water tables because it removes all exfiltrated groundwater from the system once it exits the subsurface, therefore not allowing exfiltrating groundwater to re-infiltrate. This effect is most pronounced in areas where the water table is close to the surface and for low-flow periods. The inclusion of two-way feedback also reduces the sensitivity of simulated GW levels to the magnitude of the hydraulic conductivity. This result highlights the need for additional data on other system states to improve the calibration of regional scale models that explicitly simulate two-way SW-GW interactions.