Enter claim and coverage details
Example data table
| Scenario | Fee | Sessions | Network | Allowed % | Deductible left | Copay | Coinsurance |
|---|---|---|---|---|---|---|---|
| Typical coverage | $95 | 10 | In-network | 100% | $300 | $20 | 20% |
| Lower allowed rate | $120 | 8 | Out-of-network | 70% | $0 | $0 | 40% |
| Visit limit impact | $80 | 16 | In-network | 100% | $500 | $15 | 10% |
Use these rows to sanity-check your entries. Results depend on your policy rules and provider billing practices.
Formula used
- Total billed = session fee × total sessions.
- Covered sessions = min(total sessions, covered visit limit).
- Allowed amount = covered billed × (allowed percent ÷ 100).
- Deductible applied per session = min(deductible remaining, allowed for that session).
- Coinsurance per session = (allowed − deductible applied) × (coinsurance % ÷ 100).
- Copay per session follows the selected timing rule.
- Covered member cost = deductible + copay + coinsurance, capped by OOP max if provided.
- Insurer pays = allowed − covered member cost.
- Balance billing (out-of-network estimate) = max(0, billed − allowed).
- Estimated member total = covered member cost + balance billing + not-covered sessions.
How to use this calculator
- Enter the session fee and the number of sessions you expect.
- Select network status and set an allowed percent if needed.
- Fill in deductible remaining, copay, and coinsurance.
- If your plan has limits, set a covered visit limit.
- Optionally add OOP max remaining to cap covered costs.
- Click Calculate to view totals above the form.
- Use Download CSV or Download PDF to share results.
Session volume and fee exposure
A 12-session plan at 110 per visit totals 1,320 billed. If only 10 sessions are covered, the remaining 2 sessions stay fully member-paid. Raising the fee from 110 to 125 increases billed totals by 180. Plan monthly budgeting, such as 3 sessions for 4 months. Confirm benefits before scheduling each block.
Deductible phase and turning point
When deductible remaining is 300 and allowed per session is 100, the first three covered sessions primarily pay down deductible. After it reaches zero, the same allowed amount moves into coinsurance and copay math, often reducing per-visit variability. If an out-of-pocket cap of 500 remains, the model stops covered member charges once the cap is reached, shifting more allowed cost to the insurer.
Coinsurance sensitivity testing
Coinsurance is a percentage of allowed after deductible. Moving coinsurance from 20% to 30% raises member share by 10 per 100 allowed. Over 8 covered sessions, that change adds about 80 to member cost. If allowed percent drops from 100% to 75% on a 120 fee, allowed becomes 90, and a 30% coinsurance becomes 27 per visit.
Copay timing differences
Some policies charge copay even while deductible is being met, while others apply copay only after. With a 20 copay and three deductible-heavy visits, the “always applies” rule adds up to 60 more than the “after deductible” rule, keeping insurer payment lower early on. If copay is 35 and sessions are weekly, the cash-flow impact is 140 per month across four visits, even before coinsurance.
Out-of-network balance billing risk
If billed is 140 and allowed is 98, the 42 gap can be balance billed. Across 6 covered sessions, that gap adds 252 to member cost. Combining lower allowed percent with coinsurance can produce higher member totals even when the visit count stays unchanged. Many plans do not apply balance bills to deductibles or caps, so treat this amount as an additional risk buffer.
FAQs
1) What is “allowed percent of billed”?
It estimates the insurer’s allowed amount as a share of the provider’s billed fee. Deductible and coinsurance apply to the allowed amount, while the difference may become balance billing when out-of-network.
2) How is the deductible applied across sessions?
The calculator applies deductible to each covered session’s allowed amount until the remaining deductible reaches zero. After that point, coinsurance and copay become the main covered member costs.
3) What happens when I enter an out-of-pocket maximum remaining?
Covered member costs are capped once the remaining out-of-pocket maximum is exhausted. When the cap is reached, the model shifts the remaining allowed cost for covered sessions to the insurer estimate.
4) How does a covered visit limit change totals?
Covered sessions are capped at the visit limit. Sessions beyond the limit are treated as not covered and remain fully member-paid at the billed session fee, increasing the effective cost per session.
5) Why does out-of-network often look more expensive?
Out-of-network estimates can include balance billing: billed minus allowed. That amount is added to the member total on top of deductible, copay, and coinsurance, so the same visit count can produce higher costs.
6) Do the CSV and PDF include my full inputs and results?
Yes. Exports include key inputs, totals, and per-session effectiveness metrics. For deeper auditing, keep your insurer’s Explanation of Benefits nearby and compare allowed amounts, member responsibility, and any balance bills.