| Scenario | Deductible | OOP Max | Coinsurance | Monthly Premium | Other Costs |
|---|---|---|---|---|---|
| Balanced plan | $1,500 | $6,500 | 20% | $210 | $2,800 |
| Low premium, high deductible | $3,500 | $8,500 | 30% | $135 | $1,900 |
| Higher premium, richer coverage | $750 | $4,500 | 10% | $320 | $3,600 |
Numbers are illustrative only and may not match your plan.
- Copays: total copays = (primary copay × primary visits) + (specialist copay × specialist visits) + (rx copay × fills).
- Deductible remaining: remaining = max(0, annual deductible − met to date). If copays apply to the deductible, they reduce remaining first.
- Paying the deductible: deductible paid on other costs = min(other covered costs, deductible remaining after copays).
- Coinsurance: costs after deductible = max(0, other covered costs − deductible paid). User coinsurance = costs after deductible × coinsurance rate.
- Out-of-pocket cap: eligible spending is capped by remaining out-of-pocket capacity, based on your “met to date” entry and whether copays count.
- Total annual cost: medical cost after cap + annual premium (if included).
- Enter your plan’s deductible, out-of-pocket maximum, and coinsurance percent.
- Add what you have already paid this year for deductible and out-of-pocket totals.
- Set copays and expected visits and prescription fills for the rest of the year.
- Estimate “other covered costs” using allowed amounts from recent bills or provider estimates.
- Match your plan rules using the toggles for how copays are credited.
- Click Calculate to see a detailed breakdown plus export options.
Deductible progress and remaining exposure
A deductible sets the first layer of cost sharing. For example, a $1,500 deductible with $300 already met leaves $1,200 remaining at the start. The calculator reports both the starting and projected ending remaining balance, helping you see whether your planned care will satisfy the deductible during the year. If copays apply, credited amounts reduce deductible remaining sooner for services.
Copay driven spending patterns
Copays act like fixed fees that accumulate quickly with frequent services. Using the sample inputs, four primary visits at $25, two specialist visits at $45, and 12 prescription fills at $12 total $314 in copays. If your plan counts copays toward the out-of-pocket maximum, that $314 also moves you closer to the annual cap. Raising specialist visits from two to five adds $135 copays alone.
Coinsurance sensitivity after deductible
After the deductible is satisfied, coinsurance applies to the allowed amount. With $2,800 in other covered costs and $1,200 deductible remaining, $1,200 is paid at 100%, leaving $1,600 subject to coinsurance. At 20% coinsurance, your share is $320 and the plan share is $1,280, a split the tool displays as user and plan totals. At 30% coinsurance, the same $1,600 would cost $480 instead yearly.
Out-of-pocket maximum protection
The out-of-pocket maximum limits eligible spending when a year becomes expensive. If the maximum is $6,500 and you have already met $700, the remaining capacity is $5,800. The calculator caps eligible costs based on this remaining capacity and shows any savings created when projected costs would otherwise exceed the limit. When cap is ignored, set the maximum field to 0.
Premium weighted annual outlook
Premiums can outweigh medical spending for low-use years. A $210 monthly premium equals $2,520 annually, which the tool can include or exclude from the total. Comparing scenarios highlights tradeoffs: higher premiums can pair with lower deductibles and coinsurance, while lower premiums can shift more risk into deductible and coinsurance exposure. For high-use years, premiums plus capped medical costs clarify budgeting.
1) What is the “allowed amount” used in the calculator?
It is the negotiated price that cost sharing applies to. Enter expected allowed charges for labs, imaging, procedures, and similar services. Billed charges can be higher and may not match what your plan uses.
2) Do copays always apply to the deductible?
Not always. Many plans treat copays as separate payments that do not reduce the deductible, while some designs credit them. Use the “Copays apply to deductible” option to match your plan rules.
3) What does coinsurance mean after the deductible is met?
Coinsurance is your percentage of allowed costs after the deductible layer. If coinsurance is 20%, you pay 20% and the plan pays 80% until you reach the out-of-pocket maximum.
4) Why include “met to date” amounts?
They reflect what you have already paid this year. Entering them reduces the remaining deductible and out-of-pocket capacity, so projections focus on what you may still pay for the rest of the year.
5) How does the out-of-pocket maximum change the result?
When projected eligible spending would exceed the remaining out-of-pocket capacity, the tool caps it and shows savings. This models the point where the plan typically pays 100% of covered services.
6) Should premiums be included in the total annual cost?
Include premiums to compare true yearly budget impact across plans. Exclude them if you only want medical spending exposure. The toggle lets you switch views without changing the underlying deductible and coinsurance math.