Calculator Inputs
Enter plan details and expected services. Large screens show three columns; smaller screens adjust automatically.
Example Data Table
Use these sample scenarios to sanity-check your inputs.
| Scenario | Deductible | Met | OOP Max | Coinsurance | Allowed Charges | Patient Pays |
|---|---|---|---|---|---|---|
| Early year, low spend | $1,500 | $0 | $6,000 | 20% | $350 | $350 |
| Mid year, deductible nearly met | $2,000 | $1,700 | $7,000 | 30% | $1,500 | $740 |
| Copay-heavy visits | $1,000 | $500 | $4,500 | 10% | $1,200 | $680 |
| Approaching maximum cap | $3,500 | $3,500 | $5,000 | 20% | $8,000 | $1,500 |
Formula Used
- Deductible remaining = max(0, annual deductible − deductible met).
- Out-of-pocket remaining = max(0, maximum − amount met).
- Allowed per service = unit allowed × quantity.
- Copay total = unit copay × quantity.
- Deductible applied = min(allowed after copay, deductible remaining).
- Coinsurance = (allowed after copay and deductible) × patient rate.
- Patient responsibility = copay + deductible applied + coinsurance.
- Maximum cap rule: patient responsibility cannot exceed remaining maximum.
- Net after HSA/FSA = max(0, patient pays − HSA/FSA balance).
How to Use This Calculator
- Enter your deductible, maximum, and year-to-date amounts.
- Set your coinsurance percentage after the deductible.
- List expected services using allowed costs and quantities.
- Add copays only when they apply to that service.
- Choose whether each service is subject to the deductible.
- Click Calculate to see totals and breakdown.
- Use CSV or PDF to compare different plan scenarios.
Deductible Runway and Timing
Deductible impact is mainly about timing. With a $1,500 deductible and $300 already met, you face $1,200 before coinsurance begins. If you expect two $150 visits, a $220 lab, and $600 imaging, allowed charges total $1,120. With two $25 copays, $1,070 remains deductible-eligible, so you almost finish the runway in one month. If the deductible is met midyear, rerun the same services to see the shift from deductible dollars to coinsurance dollars, and update your forecast before scheduling care.
Coinsurance Sensitivity After the Deductible
After the runway is cleared, the patient rate drives variability. On a $2,000 post‑deductible amount, 20% coinsurance is $400, while 30% is $600. If only $500 remains after copays and deductible, 20% costs $100 and 30% costs $150. Use the calculator to test how small rate changes shift your annual budget.
Out-of-Pocket Maximum and the Cap Effect
The maximum works like a hard ceiling for covered cost sharing. If your out-of-pocket maximum is $6,000 and you have already met $5,200, only $800 remains. When the scenario totals $1,450 of patient responsibility, the tool caps patient pay at $800 and reallocates the extra $650 to the plan-paid total. This matters most late in the year.
Service Mix Modeling with Copays and Deductible Flags
Different services can follow different rules. Marking “Subject To Deductible” helps model items like imaging and labs, while “No” fits fixed-copay benefits. Example: a prescription at $90 with a $10 copay and no deductible exposure stays predictable even when the deductible is unmet. A therapy line at $140 × 4 with a $20 copay can be modeled separately.
Scenario Testing for Plan Comparisons
Compare plans by running the same service list under different inputs. Build a baseline month (routine visits and medications) and a shock month (imaging, urgent care, therapy). A $1,000 deductible with 30% coinsurance may look cheaper early, but a $2,000 deductible with 10% coinsurance can win under larger claims. Export CSV or PDF to keep results consistent.
FAQs
1) What does “allowed cost” mean here?
Allowed cost is the plan-negotiated amount used for cost sharing. If billed charges differ, your responsibility is typically based on the allowed amount, not the sticker price.
2) Do copays count toward the out-of-pocket maximum?
Many plans count copays toward the maximum, but rules vary by plan and network. This calculator assumes copays contribute to your total out-of-pocket spending for the cap.
3) Why can I mark a service as not subject to the deductible?
Some benefits apply copays or coinsurance without requiring deductible first. Marking “No” helps model services like certain prescriptions or preventive visits under plan rules.
4) Does the calculator include non-covered services or balance billing?
No. It models covered, in-network cost sharing using allowed amounts. Non-covered charges, out-of-network penalties, and balance billing can change totals significantly.
5) How should I use the HSA/FSA balance field?
It estimates your net cash cost after using available tax-advantaged funds. It does not change the plan’s cost sharing; it only offsets what you pay out of pocket.
6) Can I compare two plans with different deductibles and coinsurance?
Yes. Run the same service list twice, changing plan inputs each time. Export CSV or PDF for each run to compare patient totals and component breakdowns side by side.