Enter Plan and Usage Details
How to use this calculator
- Choose your currency, age, and basic risk factors.
- Select plan tier, network type, and coverage type.
- Enter deductible, out-of-pocket maximum, and coinsurance.
- Add expected annual usage and copays for visits.
- Optional: add income, subsidy cap, and employer contribution.
- Press Calculate and review premium, out-of-pocket, and total cost.
Formula used
This estimator uses a transparent factor model to approximate premium and a standard cost-sharing model for expected out-of-pocket.
- Gross Monthly Premium = Base × AgeFactor × TobaccoFactor × HealthFactor × RegionFactor × NetworkFactor × TierFactor × CoverageFactor × DependentFactor
- Subsidy (monthly) = max(0, GrossPremium − min(GrossPremium, Income×Cap%÷12))
- Net Monthly Premium = max(0, (GrossPremium − Subsidy) − EmployerContribution)
- Coinsurance Cost = max(0, AllowedSpend − Deductible) × Coinsurance%
- Expected Out-of-Pocket = min(OOPMax, Deductible + CoinsuranceCost + Copays)
- Total Annual Cost = NetAnnualPremium + ExpectedOOP − AnnualHSA
Example data table
| Scenario | Age | Tier | Network | Deductible | OOP Max | Allowed Spend | Typical Result |
|---|---|---|---|---|---|---|---|
| Balanced coverage | 42 | Silver | PPO | 2,000 | 8,000 | 3,500 | Moderate premium, moderate cost sharing |
| Low premium focus | 30 | Bronze | EPO | 6,500 | 9,000 | 2,000 | Lower premium, higher deductible exposure |
| Low cost sharing | 55 | Gold | PPO | 1,000 | 6,000 | 8,000 | Higher premium, lower point-of-care costs |
| High usage planning | 60 | Platinum | HMO | 500 | 4,500 | 18,000 | Highest premium, strongest protection |
Premium Drivers
Base monthly premium starts at 280 for an average adult in your local market. Age factors rise from 0.85 at 18–25, to 1.20 at 35–44, 2.00 at 55–64, and 2.40 at 65+. Tobacco adds 20%, and health risk ranges from 0.95 to 1.25. Region multipliers run 0.90 to 1.30. Network choices shift costs from 0.95 to 1.08. Metal tiers scale 0.85 for Bronze to 1.30 for Platinum. Coverage is 1.00 individual and 2.60 family; each dependent adds 12%.
Cost Sharing Math
Expected out-of-pocket combines deductible, coinsurance, and copays, capped by your out-of-pocket maximum. If allowed spend is 3,500, deductible is 2,000, and coinsurance is 20%, then coinsurance applies to 1,500 and equals 300. Medical out-of-pocket becomes 2,300 before copays. Add copays such as two primary visits at 35, six prescriptions at 25, and one ER visit at 350. If the sum exceeds your out-of-pocket maximum, the model caps it.
Net Premium Adjustments
The calculator can estimate a subsidy by limiting premium to a percent of income. With 50,000 annual income and a 9% cap, the premium cap is 375 per month. If modeled gross premium is 520, the estimated subsidy is 145. Employer contributions reduce the remaining premium further. With 100 employer help, the net premium becomes 275 monthly. Health account credits can reduce the annual total.
Scenario Planning
Use the same expected usage to compare plan designs. A Bronze plan may reduce premium by about 15%, but raises deductible exposure. A Gold plan increases premium roughly 15%, yet lowers expected point-of-care spending under higher utilization. Track the break-even point where higher premiums are outweighed by lower coinsurance and a lower effective out-of-pocket. Run two scenarios and compare total annual cost.
Multi-Year Projection
Projection multiplies today’s premium and expected out-of-pocket by (1+inflation)^year. At 6% inflation, a 5,000 annual total becomes about 5,300 in year one and 5,955 by year three. Use the line chart to see compounding, and adjust inflation to reflect renewal pressure across your planning horizon.
FAQs
1) What does “allowed spend” represent?
It is your expected yearly in-network charges that count toward deductible and coinsurance. Enter a realistic number from past bills or provider estimates, excluding services your plan does not cover.
2) How is the premium estimate calculated?
The tool multiplies a base premium by factors for age, tobacco use, health risk, region, network, tier, coverage type, and dependents. It produces a planning estimate, not an insurer quote.
3) How does the subsidy estimate work?
When enabled, the model caps gross premium at a chosen percent of annual income. The difference between gross premium and the cap becomes the estimated monthly subsidy, before employer contributions are applied.
4) Why can out-of-pocket be capped?
Plans usually limit eligible cost sharing with an out-of-pocket maximum. The calculator adds deductible, coinsurance, and copays, then caps the total at the out-of-pocket maximum you enter.
5) How should I choose the inflation rate?
Use a conservative annual range that reflects local premium trends. If unsure, try 4–8%. Run multiple projections to see how budget needs shift under different renewal assumptions.
6) How do I compare two plans fairly?
Keep your expected usage the same, then change only the plan design inputs. Compare net annual premium, expected out-of-pocket, and total annual cost. Export CSVs to build a side-by-side comparison.