Example data table
These examples use simple assumptions and sample pricing.
| Example | Age | Plan level | Monthly premium | Deductible | Expected member spend | Estimated total annual cost |
|---|---|---|---|---|---|---|
| Low usage | 29 | Bronze | $310 | $6,500 | $420 | $4,140 |
| Moderate usage | 41 | Silver | $520 | $3,000 | $1,850 | $8,090 |
| Higher usage | 57 | Gold | $760 | $1,000 | $3,400 | $12,520 |
Formula used
- Annual premium = Monthly premium × 12.
- Estimated monthly premium (estimate mode) = Base(21/Silver) × AgeFactor × PlanLevelFactor × NetworkFactor × TobaccoFactor × RegionFactor.
- Member cost per service uses copays, then deductible, then coinsurance (where applicable).
- Deductible logic: Member pays allowed amounts until deductible is met.
- Coinsurance logic: After deductible, member pays (Coinsurance%) of remaining allowed.
- Out-of-pocket cap: Member medical/pharmacy spend is limited to OOP maximum.
- Total annual cost = Annual premium + Expected member medical/pharmacy spend.
How to use this calculator
- Choose estimate if you need a planning premium, or manual if you have a quote.
- Enter the plan’s deductible, out-of-pocket maximum, copays, and coinsurance.
- Estimate your annual usage (visits, prescriptions, labs, imaging).
- Adjust allowed amounts to better match local pricing.
- Press Calculate to see your results above the form.
- Use Download CSV or Download PDF to save the estimate.
Premium inputs and rating levers
This calculator estimates a monthly premium from five drivers: age, plan level, network type, tobacco status, and a regional factor. Base pricing starts at a 21-year-old Silver reference amount, then scales with an age curve and plan multipliers. Use manual premium mode when you already have a quote, and keep the other fields for cost sharing.
Deductible, coinsurance, and copays
Member costs are built from copays for common visits and prescriptions, then deductible payments, then coinsurance on remaining allowed charges. If a service is set to "deductible applies," allowed amounts first reduce the remaining deductible. After the deductible is met, coinsurance applies as a percentage of the remaining allowed amount. Copays can optionally count toward the deductible, depending on plan rules.
Utilization and allowed amounts
The usage section converts annual counts into allowed charges using negotiated price estimates per service. Primary care, specialists, urgent care, emergency room, labs, imaging, and prescriptions each have editable allowed values, so you can reflect local market pricing. Preventive care is modeled as covered at 100% and does not add to the member total. Changing counts is the fastest way to stress-test a plan.
Out-of-pocket maximum as a ceiling
Out-of-pocket maximum limits member medical and pharmacy spending for the year, excluding premiums. When member cost sharing exceeds the remaining OOP limit, the excess is shifted to the plan in this simplified model. This makes the OOP maximum the key risk number for high-usage scenarios. Comparing two plans often comes down to premium differences versus OOP protection.
Scenario comparison and export workflow
Run multiple scenarios by adjusting plan level, premium mode, and utilization patterns, then download each output as CSV or PDF. Compare annual premium, expected member spend, and total annual cost side by side. A cost curve graph helps visualize how total cost changes as medical spend rises. Use consistent allowed amounts across scenarios to keep comparisons fair. Document assumptions before sharing.
FAQs
What does "allowed amount" mean here?
It is a simplified estimate of the negotiated price for a service. The calculator multiplies counts by allowed amounts to model charges, then applies copays, deductible rules, coinsurance, and the out-of-pocket maximum.
Does the premium estimate include tax credits or subsidies?
No. The premium estimate is a gross planning number based on age and plan factors. If you receive a credit, subtract it from the monthly premium manually to see a net-cost view.
How are prescriptions handled?
Generic and brand fills are modeled using either copays or deductible plus coinsurance, depending on your deductible toggle. Adjust fill counts and allowed amounts to match your pharmacy pricing and formulary.
Why can my member spend differ from allowed totals?
Copays are fixed amounts and may be lower or higher than the allowed price. The model also shifts costs to the plan after the out-of-pocket maximum is reached, which changes the relationship between allowed charges and member spend.
What is the cost curve graph showing?
It plots total annual cost as medical spend increases, using annual premium plus cost sharing from deductible, coinsurance, and the out-of-pocket cap. The marker highlights your current scenario based on your inputs.
Can I use this to compare two plans fairly?
Yes. Keep utilization and allowed amounts consistent, then change plan level, premium, and cost-sharing terms. Save each run as CSV or PDF so you can compare annual premium, member spend, and total annual cost.