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| Scenario | Funding | Members | Annual premium | Employer annual | Total PMPM |
|---|---|---|---|---|---|
| Plan A | Fully insured | 140 | USD 1,950,000.00 | USD 1,320,000.00 | USD 1,470.24 |
| Plan B | Level-funded | 140 | USD 1,720,000.00 | USD 1,245,000.00 | USD 1,388.10 |
| Plan C | Self-funded | 140 | USD 1,520,000.00 | USD 1,180,000.00 | USD 1,316.67 |
Enrollment drives every per-member metric. Using the default scenario of 75 employees, 25 spouses, and 40 children with 90% participation, the model plans for 68 employees, 22 spouses, and 36 children, or 126 members. Adjust participation to stress-test open enrollment outcomes and eligibility changes. If you bundle families, set family counts carefully to avoid double-counting dependents. Use member counts to align quotes with payroll deductions.
Monthly premiums are summed by covered lives, then adjusted for wellness discounts and tobacco surcharges. In the example, per-member premiums of 520, 410, and 220 produce 52,300 monthly before adjustments. A 3% wellness discount lowers this to 50,731. Employer contributions of 80% for employees and 60% for dependents allocate about 37,298 monthly to the employer and 13,433 to employees. Set contributions to match budgets and goals.
Allowed claims represent total negotiated medical spend before member cost sharing. With allowed assumptions of 4,200 per employee, 5,200 per spouse, and 2,600 per child, annual allowed claims estimate 493,600. The calculator approximates out-of-pocket using deductible, coinsurance, copays, and the out-of-pocket maximum. With a 1,500 deductible, 80% plan share, 25 copay, and 2.5 visits, estimated out-of-pocket is about 2,046 per member. Review pharmacy carve-outs separately for better precision.
Administrative and broker fees are modeled per employee per month, supporting quick scenario testing. For insured plans, premium taxes and fees apply as a percentage of premium. For funded arrangements, stop-loss replaces taxes, and optional risk margin or corridor loads help budget volatility. In the example insured case, annual admin and broker fees total 29,376 and taxes add about 15,219. Validate contracts for fees and caps.
PMPM converts totals into a comparable metric across group sizes. In the example, combined annual cost is about 931,526, which equals roughly 616 PMPM. Employer-only cost is about 513,000, or 339 PMPM. Use the trend input to estimate next-year budgets; at 5% trend, the combined total projects to about 978,102. Track results by tier to compare deductibles versus premiums. Export CSV to share scenarios internally.
Allowed claims are the total negotiated medical costs before member cost sharing. They help estimate expected plan-paid claims for funded budgeting, and they also support comparing tiers with different deductibles and copays.
It uses a simple expected-value approach: deductible plus member coinsurance on remaining allowed spend, capped by the out-of-pocket maximum, then adds copays times average visits. It is a planning proxy, not a distribution model.
Use bundle pricing when your carrier quote provides a family rate and you can estimate the number of enrolled families. The calculator applies the family premium to that count and employee premium to remaining employee-only enrollments.
Premium taxes and certain state fees typically apply to insured premiums. Funded plans usually replace those with stop-loss premiums and administrative fees. Confirm local rules and carrier invoice details for your specific market.
A corridor is a cushion above expected plan-paid claims to reduce the chance of deficit in a level-funded arrangement. It is modeled as a percentage of expected plan-paid claims and can be aligned to contract terms.
Trend is a straight-line projection applied to annual totals to estimate next-year budgets. Use a conservative value if you expect utilization or unit costs to rise, and adjust it after reviewing renewal factors and claims experience.
Important Note: All the Calculators listed in this site are for educational purpose only and we do not guarentee the accuracy of results. Please do consult with other sources as well.