Calculator Inputs
Example Data Table
| Scenario | Premium / month | Deductible | Coinsurance | Other allowed costs | Estimated total out-of-pocket |
|---|---|---|---|---|---|
| Low use | $220.00 | $2,000.00 | 20% | $600.00 | $3,495.00 |
| Moderate use | $450.00 | $1,500.00 | 20% | $2,500.00 | $7,355.00 |
| High use | $600.00 | $1,000.00 | 30% | $12,000.00 | $11,500.00 |
Formula Used
- Net Premium = max(0, Gross Premium − Subsidy) × Coverage Months
- Copays = (Visits × Copay) summed across service types
- Deductible Paid = min(Deductible Remaining, Other Allowed Costs)
- Coinsurance = Remaining Allowed Cost × Coinsurance Rate (split by network share)
- Out-of-pocket Cap limits eligible covered cost-sharing (not premiums)
- Balance Billing estimates extra charges on out-of-network costs
- Total Out-of-Pocket = Premiums + Medical (after cap) + Non-covered − Reimbursements
- Tax Savings (estimate) = Pre-tax Contribution × Marginal Tax Rate
How to Use This Calculator
- Enter your coverage months and monthly premium details.
- Fill in deductible, coinsurance, and your out-of-pocket maximum.
- Add expected visits, prescriptions, and other allowed service costs.
- If relevant, estimate out-of-network share and higher cost-sharing.
- Include non-covered expenses and reimbursements for a complete view.
- Click Calculate to see totals above the form.
- Download CSV or PDF to save your scenario for planning.
Premium and Subsidy Inputs
Premiums are steady, so start with coverage months and your net monthly premium. A change of 50 per month shifts annual cost by 600 over 12 months. Subsidies or employer support reduce the premium line but do not change deductibles or coinsurance. When comparing plans, separate premium totals from medical spending to see whether premium increases are buying lower cost‑sharing overall.
Deductible Progress and Allowed Costs
Deductible remaining equals annual deductible minus the amount already met. The calculator applies remaining deductible to your expected allowed costs for covered services. If your deductible is 1,500 and you have met 200, the model treats up to 1,300 of allowed costs as fully paid by you before coinsurance begins. This helps you test mid‑year changes, such as switching plans or anticipating a procedure later.
Coinsurance, Network Mix, and Balance Billing
After deductible, coinsurance applies to the remaining allowed cost. The tool splits that amount into in‑network and out‑of‑network shares, then applies separate coinsurance rates. For example, 20% in‑network and 40% out‑of‑network can double the member share on the out‑of‑network portion. Balance billing is shown as an additional percentage on out‑of‑network allowed costs to reflect extra charges beyond the allowed amount.
Out-of-Pocket Maximum and Reimbursements
The out‑of‑pocket maximum caps eligible cost‑sharing for covered care, typically excluding premiums and sometimes excluding out‑of‑network components. Use the toggle to model whether out‑of‑network coinsurance is capped. Reimbursements, stipends, or HRA credits reduce your medical out‑of‑pocket after the cap is applied, but the calculator prevents totals from going below zero. This gives a planning floor.
Scenario Testing for Plan Selection
Use the visit and prescription fields to set a routine baseline, then adjust “other allowed costs” for one‑time events such as imaging, therapy, or surgery. Run low, moderate, and high scenarios to see how quickly you approach the cap and which plan is more resilient. If you contribute pre‑tax funds, tax savings at a 22% rate lowers net cost by 220 per 1,000 contributed.
FAQs
What does “allowed cost” mean in this tool?
It is the plan-recognized amount for covered services, before your share is applied. Coinsurance and deductible are modeled against this amount, not the provider’s billed charge.
Do premiums count toward the out-of-pocket maximum?
No. The cap typically applies to eligible cost-sharing for covered care, such as deductible, copays, and coinsurance. Premiums are added separately to show your full budget impact.
How should I estimate out-of-network share?
Use the percentage of expected covered spending likely to occur outside your network. Start with 0% if you stay in-network, then test 10% to 30% to see sensitivity.
Why is balance billing separated from coinsurance?
Balance billing reflects charges above the allowed amount, which may not count toward the cap. Keeping it separate helps you see the extra risk from out-of-network care.
How does pre-tax money change the result?
The calculator estimates tax savings by multiplying your contribution by a marginal tax rate. It does not change plan benefits, but it can reduce your net cost after taxes.
Can I compare two plans quickly?
Yes. Enter Plan A, calculate, and download the CSV or PDF. Then change inputs for Plan B and download again. Compare totals and the breakdown line items side by side.