Calculator inputs
Example data table
| Scenario | Stay days | Gross charges | Discount | Insurer pays | You pay |
|---|---|---|---|---|---|
| Routine admission | 3 | $2,950.00 | 10% | $2,123.60 | $531.40 |
| With ICU and surgery | 5 | $7,800.00 | 12% | $5,072.56 | $1,506.44 |
| High caps and exclusions | 4 | $6,100.00 | 8% | $3,238.96 | $2,373.04 |
Formula used
1) Gross charges are summed from all line items.
2) Network discount is applied across categories:
3) Caps restrict eligibility for certain categories:
EligibleICU = min(NetICU, ICUCapPerDay × ICUDays)
EligibleSurgery = min(NetSurgery, SurgeryCap) (or no cap if set to 0)
4) Exclusions reduce the eligible amount after caps:
5) Cost-sharing follows deductible, copays, then coinsurance:
AfterCopay = max(0, AfterDeductible − (AdmissionCopay + DailyCopay × StayDays))
MemberCoinsurance = AfterCopay × Coinsurance%
InsurerPaysBeforeLimit = AfterCopay − MemberCoinsurance
6) Limits are applied at the end:
YouPay = CapExcess + NonCovered + Deductible + Copays + Coinsurance + OverLimit
How to use this calculator
- Enter your expected stay days and ICU days.
- Fill in hospital charges for each cost category.
- Set your discount, caps, and non-covered percentage.
- Enter policy cost-sharing: deductible, copays, coinsurance, and limits.
- Press Calculate to see the estimated split.
- Use CSV or PDF to save and share the breakdown.
Build a realistic bill profile
Room, ICU, surgery, labs, imaging, and professional fees often drive most inpatient claims. In a sample case, a 4‑day stay with 1 ICU day totals $5,570 gross: room $720, ICU $600, surgery $2,500, doctor $700, labs $350, medicines $220, imaging $400, plus $80 misc. If you change stay length, the tool updates daily copays.
Translate gross charges into contracted net
Many plans apply negotiated discounts when a provider is in-network. With a 12% discount, the same $5,570 becomes $4,891.60 net. This calculator shows the discount amount ($678.40) and preserves category detail, so you can identify the biggest cost drivers quickly.
Apply caps and exclusions to find eligible spend
Sub-limits can reduce what the insurer considers eligible. Using a room cap of $150/day and ICU cap of $500/day, eligible room becomes $600 and eligible ICU $500. If surgery is capped at $2,000, eligible surgery becomes $1,760 after the discount. Across categories, caps create $491.60 of excess. A 5% non-covered rate then removes $220 from eligibility, leaving $4,180 eligible.
Model deductible, copays, and coinsurance
After eligibility is set, cost-sharing usually applies in sequence. If $150 of deductible remains, the balance is $4,030. Add a $30 admission copay and $10/day for 4 days ($70), leaving $3,930. At 20% coinsurance, member coinsurance is $786 and insurer responsibility becomes $3,144 before benefit limits. If out-of-pocket max remaining is $900, coinsurance reduces by $136.
Stress-test limits and export insights
Coverage limits can change the final split dramatically. If remaining coverage is $10,000, the insurer pays the full $3,144. Your estimated out-of-pocket is $1,747.60, made up of cap excess ($491.60), non-covered ($220), deductible ($150), copays ($100), and coinsurance ($786). If coverage remaining were $2,500, the $644 shortfall becomes “over limit” and shifts to you. Export CSV for audit trails, or PDF for pre-authorization discussions with your care team securely.
FAQs
1) Does this replace my insurer’s final explanation of benefits?
No. This is an estimate using the inputs you provide. Actual pricing, coding, network discounts, and medical necessity reviews can change what is allowed and paid.
2) What should I enter if I do not know the exact charges?
Use the hospital’s estimate, prior bills, or a conservative range. Start with room and procedure costs, then add labs, imaging, and medicines to avoid underestimating.
3) What does “non-covered portion” represent?
It approximates exclusions such as non-formulary medicines, non-approved services, or plan restrictions. It is applied after caps, reducing the amount eligible for cost-sharing.
4) How is ICU handled if it is part of my stay?
ICU days are included in total stay days for daily copays. ICU charges also use their own rate and cap, helping you see the incremental impact of ICU time.
5) How does the out-of-pocket maximum affect the results?
If you enter an out-of-pocket max remaining, the tool caps deductible, copays, and coinsurance at that amount. Items like cap excess or non-covered charges typically remain your responsibility.
6) Can I use the exports for pre-authorization or reimbursement?
Yes, as supporting documentation. CSV is useful for auditing line items, while PDF provides a clean summary for discussions. Always attach provider estimates and policy documents when available.