| Household | Tier | Net premium (annual) | Out-of-pocket (avg) | Total (avg) |
|---|---|---|---|---|
| 2 adults (35), 2 children (10) | Balanced | ₨240,000 | ₨110,000 | ₨350,000 |
| 2 adults (45), 1 child (7) | Enhanced | ₨310,000 | ₨90,000 | ₨400,000 |
| 2 adults (40), 0 children, 1 senior (62) | Premium | ₨480,000 | ₨140,000 | ₨620,000 |
PostCopayAllowed = Σ(Count × max(UnitCost − Copay, 0))
DeductiblePaid = min(Deductible, PostCopayAllowed)
CoinsurancePaid = (PostCopayAllowed − DeductiblePaid) × CoinsuranceRate
OutOfPocket = min(CopaysPaid + DeductiblePaid + CoinsurancePaid, OOPMax)
- Pick your currency and set the base adult monthly premium.
- Enter household size and average ages for adults, children, and seniors.
- Select tier, network, region, and fill deductibles, coinsurance, and copays.
- Add employer contributions, subsidies, and optional dental/vision add-ons.
- Estimate annual usage: visits, labs, imaging, hospital days, and prescriptions.
- Submit to see net premium, out-of-pocket range, and total annual cost.
- Use Download CSV/PDF to save results for comparisons.
Premium drivers and household mix
The estimator starts with a base adult monthly premium and scales it by age, tier, network, and region multipliers. Adults use an age factor from 0.85 to 2.10, while children are weighted at about 55% of an adult. A family discount increases by 3% per additional member, capped at 12%, so larger households can reduce the blended rate.
Plan design trade-offs
Deductible, coinsurance, and the out-of-pocket maximum shape how costs shift between premium and claims. A higher deductible typically lowers premium but increases early-year spending. Coinsurance is applied after the deductible at your selected rate, up to 80%. The out-of-pocket maximum caps the combined deductible, copays, and coinsurance in the estimate.
Scenario range using utilization scaling
To show uncertainty, the calculator runs three scenarios: low usage at 0.70×, average at 1.00×, and high at 1.40× of your expected visits and prescriptions. Allowed charges are built from unit costs (visits, labs, imaging, hospital days) and then adjusted by an optional medical trend percentage. This creates a practical range for comparing plans. Use the chart to see how premiums and claims combine across each scenario.
Contributions and monthly affordability
Employer contributions and subsidies reduce the gross premium to a net premium, never below zero. When you enter a monthly budget, the tool converts the average annual total into an expected monthly cost and shows a budget gap. A positive gap means you are under budget; a negative gap indicates overspending risk.
Improving accuracy with local pricing
Default unit costs are placeholders, so update them to match your area and typical providers. For example, if specialist visits average 8,000 instead of 6,000, your estimated out-of-pocket can change materially under coinsurance. If maternity is expected, enabling the one-time event adds a single large claim, which can push results toward the out-of-pocket maximum.
FAQs
What does the base adult monthly premium represent?
It is an estimate for one adult in a typical age band (30–39). The calculator applies multipliers for age, tier, network, region, and tobacco status to build household premiums.
How are low, average, and high scenarios calculated?
The tool scales your expected annual usage by 0.70×, 1.00×, and 1.40×. It then applies copays, deductible, coinsurance, and the out-of-pocket maximum to estimate spending.
Why can my out-of-pocket stay high even with a premium plan?
Premium tiers may lower cost sharing, but heavy utilization or costly events can still reach the out-of-pocket maximum. Updating unit costs and usage inputs helps reflect your real risk.
How do employer contributions and subsidies affect results?
They reduce the gross monthly premium to a net premium, never below zero. All scenarios use the same net premium, so differences mainly come from out-of-pocket spending.
What is the difference between deductible and out-of-pocket maximum?
The deductible is what you pay before coinsurance applies to covered costs. The out-of-pocket maximum is a cap on deductible, copays, and coinsurance combined, based on the estimator’s rules.
How do I export and share my estimate?
After you submit, use Download CSV for spreadsheet comparisons or Download PDF for a printable summary. The export includes key inputs, premiums, scenario out-of-pocket values, and totals.