Calculator
Example data table
| Tier | Gross annual premium | Net annual premium | Estimated out-of-pocket | Estimated annual total | Monthly equivalent |
|---|---|---|---|---|---|
| Bronze | $11,983.38 | $9,584.21 | $1,926.00 | $11,510.21 | $959.18 |
| Silver | $14,510.94 | $11,985.39 | $1,926.00 | $13,911.39 | $1,159.28 |
| Gold | $17,410.20 | $14,739.69 | $1,926.00 | $16,665.69 | $1,388.81 |
Formula used
How to use this calculator
- Choose a tier and enter household counts and oldest age.
- Enter monthly premiums per adult and child, plus discounts or contributions.
- Fill deductible, out-of-pocket max, coinsurance, and copays from plan documents.
- Estimate yearly usage: visits, prescriptions, labs, imaging, ER, and hospital days.
- Adjust allowed costs if you have local or insurer estimates.
- Click Calculate, then download a CSV or PDF report.
Premium drivers and tier trade-offs
Premium estimates start with per‑member monthly rates, then apply regional, age, and tobacco multipliers. A 1.20 tobacco factor raises a $400 base to $480 before add‑ons. Higher tiers typically cost more in premium but reduce cost sharing. Use the tier selector to load starter benchmarks, then replace them with your quoted rates to align the model. Add-ons can include dental $18, vision $8, and accident $12 monthly easily.
Cost sharing and the deductible corridor
Deductible and out‑of‑pocket maximum shape the “corridor” where most spending occurs. In this calculator, labs, imaging, emergency care, and hospital days flow through the deductible first, then coinsurance. Example: $3,000 in eligible costs with a $2,000 deductible and 20% coinsurance yields $2,000 deductible paid plus $200 coinsurance. The OOP cap then limits totals. Use plan documents for exact deductible rules.
Modeling utilization with allowed amounts
Utilization inputs convert expected care into dollars. Office visits and prescriptions are treated as fixed copays, so frequency matters more than price. For deductible‑eligible services, the allowed amount is the negotiated figure, not the billed charge. If your local average lab is $150 instead of $120, raising the allowed amount increases deductible paid and coinsurance, which can flip the best tier for the year.
Discounts, contributions, and net premium control
Net premium is reduced by wellness discounts, employer contributions, and tax credits, all applied annually. A 5% wellness discount on $6,000 annual premium saves $300, while a $150 employer contribution saves $1,800 per year. Because contributions can exceed premium, the net premium floors at zero. Add‑ons are modeled as fixed monthly amounts so you can capture dental, vision, or accident riders.
Reading results for budgeting decisions
Focus on annual total and monthly equivalent, not premium alone. Compare how much of the total comes from predictable premium versus volatile out‑of‑pocket spending. Run three scenarios: low use, expected use, and high use by increasing imaging, ER visits, or hospital days. If totals converge across tiers, prioritize provider networks and prescription coverage. Export CSV or PDF to document assumptions for decision reviews.
FAQs
1) What does “allowed amount” mean?
It is the negotiated price the plan uses to calculate deductible and coinsurance. It is usually lower than the billed charge. Update allowed amounts with insurer estimates for more realistic out-of-pocket projections.
2) Why can net premium be zero?
Employer contributions and tax credits are applied against premium in this model. If support exceeds discounted premium, net premium is floored at zero to avoid negative costs. Out-of-pocket spending is still added to the annual total.
3) Do copays count toward the deductible here?
Office visits and prescriptions are modeled as copays that do not reduce the deductible. Many plans work this way, but some services may apply differently. If your plan applies copays to the deductible, approximate by increasing deductible-eligible allowed costs.
4) How should I compare tiers fairly?
Keep household size, region factor, and utilization the same, then compare annual total and monthly equivalent. Run low, expected, and high usage scenarios. If differences are small, evaluate provider network, drug formularies, and referral rules.
5) How do I estimate utilization numbers?
Start with last year’s claims or appointment history. Count primary and specialist visits, refills, labs, imaging, and any ER use. For uncertainty, create a conservative scenario by adding one imaging and one ER visit, and a few extra lab panels.
6) Can this replace an insurer quote?
No. It is a budgeting tool for comparing plan structures using your assumptions. Insurers set exact premiums, covered services, and cost-sharing rules. Use this calculator to test scenarios, then confirm details in plan documents before enrolling.