Example data table
| Category | Example value | Notes |
|---|---|---|
| Annual premium | $1,200 | Premiums paid over the year. |
| Deductible | $1,500 | Paid before coinsurance starts. |
| Out-of-pocket maximum | $6,000 | Caps covered medical spending. |
| Coinsurance (you pay) | 20% | Applied after deductible on eligible costs. |
| Primary visits | 3 | Copay $20 each; billed $120 each. |
| Specialist visits | 2 | Copay $40 each; billed $220 each. |
| Urgent care visits | 1 | Copay $50; billed $180. |
| Network discount | 15% | Negotiated rate reduction on billed amounts. |
| Rx billed per month | $35 | Plus an optional $10 monthly Rx copay. |
Formula used
This estimator converts billed amounts into an allowed cost using a network discount, then applies plan rules:
- Allowed cost = Billed cost × (1 − Network discount).
- Paid toward deductible = min(Allowed eligible cost, Remaining deductible).
- Coinsurance paid = (Allowed eligible cost − Paid toward deductible) × Coinsurance%.
- Copays = (Visits × Copay) + (Rx copay × 12) + other flat copays.
- Medical out-of-pocket = Deductible paid + Coinsurance paid + (Copays if they count) + Preventive paid. If an out-of-pocket maximum is set, the cappable portion is limited to that maximum.
- Total annual cost = Premium (optional) + Medical out-of-pocket − Offsets (optional).
Plans differ on what counts toward deductible and the out-of-pocket maximum, so adjust those toggles to match your plan documents.
How to use this calculator
- Enter premium, deductible, coinsurance, and out-of-pocket maximum from your plan summary.
- Estimate yearly usage: visits, ER events, inpatient days, and monthly prescriptions.
- Set copay rules to match how your plan applies copays.
- Optionally add employer contributions or tax savings as offsets.
- Press Calculate to see summary, breakdown, and sensitivity scenarios.
- Download CSV or PDF to save and compare with other options.
Plan inputs and outputs
This calculator estimates yearly out-of-pocket exposure by combining premium, deductible, coinsurance, copays, and an out-of-pocket maximum. It converts billed amounts into allowed amounts using your network discount, such as 15%, then applies plan rules. Outputs include medical out-of-pocket, total annual cost, offsets, and a monthly net figure for budgeting. When offsets are entered, such as a $500 employer HSA contribution and $200 estimated tax savings, the tool subtracts them from the annual total to produce a net cost. You can also exclude premiums to focus only on medical risk. Results update instantly after you press Calculate now.
Service and pharmacy assumptions
Utilization is modeled with visit counts and average billed costs. For example, 3 primary visits at $120, 2 specialist visits at $220, 1 urgent visit at $180, and $35 monthly prescriptions create a realistic baseline. The discount reduces each category before cost sharing, mirroring negotiated rates and helping comparisons across providers and regions.
Deductible and coinsurance mechanics
Eligible allowed costs first satisfy the remaining deductible. After that point, the calculator applies your coinsurance share, such as 20%, to the post‑deductible remainder. Flat copays are added in parallel, and an option lets you decide whether copays reduce the deductible. This structure highlights how low premiums can still yield high spending in heavy-use years.
Out-of-pocket maximum logic
The out-of-pocket maximum caps cappable medical costs. Many plans count deductible, coinsurance, and most copays toward the cap; others exclude certain copays. The toggle lets you mirror those designs. If you set a $6,000 maximum, the calculator limits capped costs to that ceiling, then adds any excluded copays after the cap is reached.
Scenario testing and reporting
The sensitivity table scales eligible costs by −20%, baseline, and +20% to show how net cost changes as care varies. The Plotly waterfall chart visualizes how premium, medical out-of-pocket, and offsets combine into net annual cost. Download CSV or PDF to keep a record, compare plans side by side, and document assumptions consistently.
FAQs
1) Does this replace my plan documents?
No. It estimates costs using your inputs. Confirm deductible rules, coinsurance, and what counts toward the out-of-pocket maximum in your official plan materials.
2) What does the network discount represent?
It approximates negotiated allowed rates by reducing billed amounts. If you are unsure, try 10–25% and observe how results change across scenarios.
3) Why are there toggles for copays counting rules?
Plans differ. Some copays reduce the deductible or count toward the out-of-pocket maximum, while others do not. Set these to match your summary of benefits.
4) Should I include premium in the total?
Include premium for full-year budgeting and plan comparisons. Exclude it if you only want to measure medical out-of-pocket exposure from care usage.
5) How are prescriptions calculated?
Monthly prescription spending is annualized, discounted, and treated as eligible cost. Monthly prescription copays are added separately, reflecting common pharmacy benefit designs.
6) Is the PDF export detailed enough for audits?
It is a simple summary report with key totals and breakdown lines. For compliance or reimbursement needs, keep your receipts and insurer explanations of benefits.