| Scenario | Premium/mo | Deductible | Coinsurance | OOP Max | Other Services | Estimated Total/Year |
|---|---|---|---|---|---|---|
| Balanced plan, moderate use | $350 | $1,500 | 20% | $6,500 | $1,200 | $5,900 |
| Low premium, higher deductible | $220 | $3,500 | 20% | $7,500 | $2,000 | $6,200 |
| Higher premium, richer copays | $520 | $750 | 10% | $4,500 | $900 | $7,000 |
| High use year, larger services | $410 | $1,000 | 20% | $4,000 | $6,000 | $8,900 |
| Minimal use year | $300 | $2,000 | 30% | $8,000 | $150 | $3,900 |
- Annual Premiums = Monthly Premium × 12
- Copays = Σ(Count × Copay) for selected services (Copay-first mode)
- Deductible-Eligible Charges = Other Services + Σ(Count × Allowed Charge) (Deductible-first mode)
- Deductible Paid = min(Annual Deductible, Deductible-Eligible Charges)
- Coinsurance Paid = max(0, Charges − Deductible Paid) × Coinsurance Rate
- Medical Spend (capped) = min(Out-of-Pocket Maximum, Copays + Deductible Paid + Coinsurance Paid)
- Total Estimated Annual Cost = Annual Premiums + Medical Spend (capped)
- Pick your plan method: Copay-first or Deductible-first.
- Enter your monthly premium, deductible, coinsurance, and out-of-pocket maximum.
- Estimate how many visits and prescriptions you expect this year.
- For Deductible-first plans, adjust allowed-charge estimates to match your area.
- Add a yearly estimate for labs, imaging, or procedures under “Other services.”
- Click Estimate Cost. Your result appears above the form.
- Use the CSV/PDF buttons to save the estimate for budgeting.
Annual Cost Drivers
Annual cost starts with premiums, then adds expected medical spending. For example, a $350 monthly premium equals $4,200 yearly before any care. If deductible is $1,500 and coinsurance is 20%, a $3,000 allowed charge can create $1,500 deductible plus $300 coinsurance. This tool converts those pieces into one annual figure for budgeting.
Utilization and Copays
Copays behave like fixed fees per service. Four primary visits at $30 add $120, while two specialist visits at $60 add $120 more. One urgent visit at $75 raises the total to $315 before prescriptions. If you fill six generic scripts at $15, that adds $90. These values are straightforward, so the estimate is sensitive to visit counts you enter.
Deductible and Coinsurance
Deductible-first plans often require paying allowed charges until the deductible is met. Suppose other services total $2,000 and your deductible is $1,500. The remaining $500 is then shared by coinsurance, such as 20%, which adds $100. When allowed charges rise, coinsurance grows linearly after the deductible, which this calculator models using your rate.
Out of Pocket Limit
Most plans cap medical spending at an out of pocket maximum, excluding premiums. If your cap is $6,500 and your modeled medical spend is $7,400, the tool limits medical spend to $6,500 and shows the savings as $900. In high use years, the cap dominates the estimate and reduces uncertainty. Set the cap to 0 only for plans without one.
Comparing Plan Scenarios
Use consistent utilization to compare plans. Plan A might have $300 monthly premium and $2,000 deductible, while Plan B has $520 premium and $750 deductible. With light use, premiums can be the largest driver, so Plan A may win. With heavy services, Plan B can benefit from lower cost sharing and a smaller cap. Export results to track options side by side. For a family, increase utilization counts and adjust service charges to reflect predictable seasonal care needs.
Copay-first adds your entered copays directly, then applies deductible and coinsurance mainly to other services. Deductible-first treats most services as deductible-eligible using allowed charges, then applies coinsurance after the deductible is met.
Use your insurer’s price estimator, recent explanations of benefits, or provider billing summaries. Enter typical in-network allowed amounts, not billed charges. If you do not know them, keep the defaults and focus on premiums, deductible, and utilization.
Usually no. Most plans cap medical cost sharing, while premiums are paid regardless. This calculator keeps premiums separate and applies the cap only to modeled medical spending.
Many plans set the out of pocket maximum at or above the deductible. If your deductible is higher, it may indicate you entered the wrong number or the plan uses separate limits. The calculator still runs, but results may be less realistic.
Add an annual total for labs, imaging, therapy, procedures, and anticipated one-time events. If you have a known treatment plan, use the expected in-network allowed amount. Start conservative, then run a higher and lower scenario to see the range.
Yes. Keep utilization inputs the same for both plans, then change only plan fields like premium, deductible, coinsurance, and the out of pocket maximum. Compare total annual cost and the breakdown chart, then export each estimate to document your decision.