Health Insurance Payment Calculator

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Premium and Contributions

Monthly premium (gross)

The full monthly premium before employer help.

Employer contribution (monthly)

Enter 0 if none.

HSA/FSA contribution (monthly)

Optional budgeting contribution, shown in cash outlay.

Cost Sharing

Deductible (annual)

Coinsurance (your share %)

Applied after deductible to “other services”.

Out-of-pocket maximum (annual)

Caps member cost-sharing in this model.

Deductible already met

Out-of-pocket already spent

Copays count toward OOP maximum? Yes No

Most plans count copays, but rules vary.

Copays apply before deductible? Yes No

If “No”, copays are treated as deductible/coinsurance items (approximation).

Copays count toward deductible? No Yes

Optional modeling toggle.

Routine Visits and Copays

Primary care visits (annual)

Primary care copay

Specialist visits (annual)

Specialist copay

Urgent care visits (annual)

Urgent care copay

Emergency room visits (annual)

Emergency room copay

Prescription Copays (Annual Fills)

Generic fills

Generic copay

Preferred brand fills

Preferred brand copay

Non-preferred brand fills

Non-preferred brand copay

Specialty fills

Specialty copay

Other Covered Services

Estimated allowed amount (annual)

Labs, imaging, procedures, hospital care, and similar items.

Optional Tax Savings

Apply estimated tax savings? No Yes

Applies to your premium plus HSA/FSA contributions.

Estimated tax rate (%)

Calculate Clear

Example Data Table

A sample scenario showing typical inputs and the resulting projections.

Formula Used

• Annual premium (member): (Monthly Premium − Employer Contribution) × 12
• Copay total: Σ(Count × Copay) across visits and prescription tiers
• Remaining deductible: max(0, Deductible − Deductible Met)
• Other services cost share: min(Allowed, Remaining Deductible) + (Allowed − Deductible Portion) × Coinsurance%
• Out-of-pocket projection: additional spending is capped by max(0, OOP Max − OOP Spent) (copay behavior controlled by toggles)
• Effective annual cost: (Annual Premium + Projected OOP) − Tax Savings

How to Use This Calculator

1. Enter the monthly premium and any employer contribution.
2. Add your deductible, coinsurance percentage, and out-of-pocket maximum.
3. Estimate routine visits and prescriptions using annual counts.
4. Enter an annual allowed amount for other covered services.
5. Click Calculate to view the results and chart above the form.
6. Export your scenario using the CSV and PDF buttons.

Premium Inputs That Mirror Real Billing

Monthly premiums are typically billed per enrollee and coverage tier. In many plans, individual premiums cluster between 250 and 650 per month, while family premiums often range from 900 to 1,800. This calculator converts the monthly figure to an annual baseline and separates any employer contribution so you can see what you actually pay. If you pay biweekly, estimate monthly by multiplying the payment by 26/12.

Deductible, Coinsurance, and Maximum Protection

Annual deductibles commonly fall between 500 and 4,000 for individuals, with coinsurance frequently set near 10% to 30% after the deductible. The out-of-pocket maximum creates a ceiling; many plans place it between 3,000 and 9,000 for an individual. The model applies remaining deductible first, then coinsurance, and stops additional member spending once the maximum is reached. Enter deductible and out-of-pocket already paid so projections reflect the rest of year.

Copays and Routine Utilization Planning

Office visit copays often sit around 20 to 50 for primary care and 40 to 90 for specialists. Urgent care copays may be 50 to 100, and emergency room copays can be 200 to 500. By entering expected counts for visits and prescriptions, the calculator estimates predictable expenses that can dominate costs in low-claim years.

Scenario Testing With Service Costs

For labs, imaging, procedures, or hospital care, you can enter an annual allowed amount. A single outpatient procedure might be 1,200 to 3,500, while a short inpatient stay can exceed 8,000. Changing this one input quickly shows how total spending shifts from premium-driven to cost-sharing-driven, which helps compare high-deductible versus richer copay plans.

Reporting for Budgeting and Documentation

The results panel summarizes gross premium, employer help, projected out-of-pocket, and an effective annual total. Exports include a clean CSV for spreadsheets and a concise PDF for sharing or recordkeeping. Use the chart to explain where dollars go, then save the scenario that best matches your expected year. Archive.

FAQs

1) Does this match the exact way every claim is processed?

No. It’s a planning model. Real claim rules depend on network status, benefit carve-outs, copay exceptions, and whether services are subject to deductible or flat copays.

2) What should I enter for “allowed amount”?

Use the insurer’s negotiated amount you expect in a year for labs, imaging, procedures, and hospital care. If unknown, estimate conservatively using past bills or plan cost estimators.

3) Why do you ask for “already met” amounts?

Deductible and out-of-pocket spending reset annually for many plans. Entering what you’ve already paid helps avoid double-counting and improves the remaining-year projection.

4) Do copays always count toward the out-of-pocket maximum?

Often they do, but not always. Some plan designs exclude certain charges. Use the toggle to reflect your plan document and see how much the cap changes your projection.

5) How is tax savings estimated?

If enabled, the model applies your tax rate to your annual premium plus HSA/FSA contributions. It’s a rough estimate and doesn’t replace tax advice or payroll-specific calculations.

6) What’s the best way to compare two plans?

Run at least three scenarios: low use, typical use, and high use. Compare effective annual cost, cash outlay, and how quickly you hit the deductible and out-of-pocket maximum.