- Choose the service type and network status for the visit.
- Enter an allowed amount estimate and any expected add-on fees.
- If out-of-network, enter the billed amount and allowed factor.
- Set your copay rule, copay type, deductible remaining, and coinsurance.
- Add your remaining out-of-pocket maximum for cap estimates.
- Submit to see a visit estimate and a multi-visit projection.
1) Allowed total = allowed amount + facility fee + other fees.
Out-of-network option: allowed total = billed amount × allowed factor. Balance bill = billed amount − allowed total (if positive).
2) Copay is either a fixed amount or a percent of the allowed total (capped at allowed total). Copay is applied immediately or only when deductible is already met, depending on your rule.
3) Cost-sharing base is the amount remaining after copay if you enable “apply deductible/coinsurance after copay.” Otherwise, copay-only visits skip deductible/coinsurance on the remaining allowed portion.
4) Deductible applied = min(deductible remaining, cost-sharing base).
5) Coinsurance = (cost-sharing base − deductible applied) × coinsurance rate.
6) Out-of-pocket cap limits the allowed-side patient cost to your remaining out-of-pocket maximum. Balance billing may not be capped unless you enable the option.
- This tool models one service line item plus fees. Real bills may include multiple codes.
- Plan rules vary: some copays apply after deductible, some do not.
- Out-of-network balance billing can be restricted by local regulations and contracts.
| Scenario | Network | Allowed | Copay | Deductible Left | Coinsurance | Estimated You Pay |
|---|---|---|---|---|---|---|
| Primary care visit | In-network | $150.00 | $30.00 | $500.00 | 20% | $30.00 |
| Imaging with coinsurance | In-network | $900.00 | $0.00 | $200.00 | 30% | $410.00 |
| Out-of-network specialist | Out-of-network | $700.00* | $50.00 | $0.00 | 40% | $330.00 + balance |
Copay drivers in the estimate
This tool combines copay rules, deductible status, and coinsurance to model what you pay. For a $180 allowed visit, a $30 fixed copay yields $30 when coinsurance is disabled. If coinsurance applies after copay, the base becomes $150. With 20% coinsurance and $0 deductible remaining, the estimate becomes $60 total.
Deductible interaction with services
Deductible remaining changes the mix quickly. With $600 remaining and a $900 allowed procedure, $600 is applied to deductible first. The remaining $300 then faces coinsurance. At 30%, coinsurance equals $90. Add a $0 copay and your allowed-side payment totals $690 before any out-of-pocket cap is applied.
Out-of-pocket cap behavior
The out-of-pocket remaining field caps allowed-side spending for the visit. If your calculated allowed-side cost is $410 and you have $250 remaining, the tool caps you at $250 and sets the rest to insurer responsibility on the allowed amount. This models typical plan behavior, but you should confirm whether copays count toward the cap.
Out-of-network modeling and balance bills
For out-of-network care, the allowed amount can be estimated from billed charges using an allowed factor. Example: $1,000 billed with a 70% factor creates $700 allowed and a $300 balance bill. Cost-sharing applies to the $700, while the $300 may be added on top. Use the balance-bill option only if your plan counts it.
Projection use for budgeting
The projection repeats the same visit cost and updates remaining deductible and out-of-pocket each time. If you estimate $95 per therapy session across 12 sessions, the projected total is $1,140, unless you reach the out-of-pocket cap earlier. Compare projected totals with your cash-flow plan, and export the tables for documentation. If deductible is met midseries, later visits shift from deductible to coinsurance, often lowering variability. Track visit count, service type, and network status consistently to keep the projection aligned with expected claims.
Does the copay always apply before the deductible?
Not always. Many office-visit copays apply immediately, but some services require meeting the deductible first. Use the “Copay Rule” option to match your plan.
What is the “allowed amount”?
It is the contracted or recognized price used for cost-sharing. Your insurer usually calculates deductible and coinsurance from this amount, not the provider’s sticker price.
Why can out-of-network costs be much higher?
Insurers may only recognize a portion of the billed charge. The difference can become a balance bill. This tool estimates that gap using the allowed factor you enter.
Does the out-of-pocket maximum cap everything?
Often it caps covered, allowed-side spending. Balance bills, non-covered services, and some fees may not count. Enable the balance-bill option only if your plan counts it.
Should I enable “apply deductible/coinsurance after copay”?
Enable it when your plan charges a copay and also applies deductible or coinsurance to the remaining allowed cost. If your visit is “copay only,” leave it unchecked.
How accurate is the projection?
It simulates repeated visits using the same service cost and rules while reducing deductible and out-of-pocket balances. Real-world totals vary with different services and claim processing.