Model your yearly medical costs from premium to deductible, coinsurance, and out-of-pocket maximum.
Estimates only — not financial or medical advice. Always confirm with your insurer.
Percentage you pay after deductible (e.g., 20% means you pay 20%, insurer pays 80%)
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Last updated: February 2026
You scheduled an MRI and the imaging center quoted $1,200. Your insurance card says $500 deductible and 20% coinsurance. So what will you actually pay? Most people guess wrong because they forget one number or misunderstand how the pieces stack. A common mistake: assuming the deductible is all you owe, when coinsurance adds another chunk after that. This calculator shows your estimated patient responsibility before the bill arrives—so you can budget, negotiate, or decide if a different facility makes more sense.
Medical bills follow a specific order. First, the provider submits a claim to your insurer. The insurer applies the negotiated allowed amount—usually less than the billed charge. Then your cost-sharing kicks in based on where you are in your plan year.
Deductible: The amount you pay before insurance starts sharing costs. If your deductible is $1,000 and you have only paid $200 so far, the next $800 of allowed charges comes out of your pocket.
Copay: A flat fee for specific services. Your plan might say $30 for a primary care visit regardless of what the visit actually costs. Some copays apply before the deductible, others after.
Coinsurance: Your percentage share after meeting the deductible. If the allowed amount is $1,000 and your coinsurance is 20%, you pay $200 and the insurer pays $800.
Out-of-pocket maximum: The ceiling on your annual cost-sharing. Once you hit this number, the plan pays 100% of covered services for the rest of the year.
These four pieces determine every medical bill you receive. The calculator applies them in the correct order based on your plan rules and how much you have already paid this year.
Step 1: Enter your plan details from your Summary of Benefits—deductible, coinsurance percentage, out-of-pocket max, and whether copays apply before or after the deductible.
Step 2: Enter how much you have already paid toward your deductible and out-of-pocket max this year. Check your insurer's online portal or call member services if you do not know.
Step 3: Enter the allowed amount for the service you are planning. Ask the provider or check your insurer's cost estimator tool. Use the negotiated in-network rate, not the billed charge.
Step 4: Review the breakdown. The calculator shows how much goes toward your remaining deductible, how much is coinsurance, and whether you hit your out-of-pocket max.
If you have multiple services planned, run each one separately and note how the first service changes your remaining deductible for the second.
The out-of-pocket maximum is your financial safety net. For 2025, the ACA limits individual OOP max to $9,200 and family to $18,400. Your plan may have a lower cap.
Once you hit the OOP max, the insurer covers 100% of in-network covered services. This protection matters most during expensive health events: surgeries, cancer treatment, childbirth, or chronic disease management.
What counts: Deductibles, copays, and coinsurance for covered in-network services.
What does not count: Monthly premiums, out-of-network charges above allowed amounts, non-covered services, and balance-billed amounts.
If you expect high medical costs this year, track your OOP spending carefully. Some people intentionally schedule elective procedures after hitting their max to get them at no additional cost.
Scenario 1: Emergency room visit
Sarah has a $1,500 deductible, 20% coinsurance, and $6,000 OOP max. She has paid $400 toward her deductible so far. She sprains her ankle and goes to the ER. The allowed amount is $2,800.
Scenario 2: Urgent care visit for the same injury
Same plan details. The urgent care allowed amount is $450.
The ER visit cost Sarah $990 more than urgent care for a similar evaluation. When your condition allows, lower-cost settings save money.
Before a procedure, call your insurer and ask:
Ask the provider:
Document the answers. If the final bill differs significantly from what you were told, use these notes to dispute charges.
No. Your monthly premium is a separate cost from medical expenses. The out-of-pocket maximum only includes deductibles, copays, and coinsurance you pay when receiving care. Premiums never count toward it.
After the deductible, coinsurance kicks in. If your plan has 20% coinsurance, you pay 20% of the allowed amount until you reach your out-of-pocket max. Copays for visits may also apply depending on your plan.
Emergency services are typically covered at the in-network rate even at out-of-network facilities under the No Surprises Act. However, follow-up care at that facility may not have the same protection. Always check with your insurer before non-emergency follow-ups.
The EOB shows the provider's billed charge and the allowed amount your insurer negotiated. You only pay based on the allowed amount for in-network care. The difference between billed and allowed is the provider write-off.
Yes. Call your insurer for a pre-authorization or cost estimate. Ask the provider for the procedure code (CPT) and use your insurer's cost estimator tool. This calculator helps you understand how deductible and coinsurance apply to that estimate.
It depends on your plan. Some plans have a combined medical and pharmacy OOP max, while others track them separately. Check your Summary of Benefits or call your insurer to confirm how your plan handles prescription costs.
Embedded means each family member has their own deductible cap within the family limit. Aggregate means the entire family deductible must be met before coverage kicks in for anyone. Most ACA-compliant plans use embedded deductibles.
Plans often use copays for predictable services like office visits ($25 copay) and coinsurance for variable costs like hospital stays (20% coinsurance). Some services may have copays that apply before the deductible, while others use coinsurance after the deductible.
Common questions about medical out-of-pocket costs, deductibles, coinsurance, and how this calculator works.
No. OOP caps typically exclude premiums; they cap **medical cost-share** only. Premiums are separate from your out-of-pocket medical expenses.
Depends on your plan. Use the toggles in the calculator to match your plan documents. Many plans have copays that apply before the deductible and count toward the OOP max, but not toward the deductible.
Allowed amount is the negotiated in-network price that your insurer has agreed to pay. We model costs on allowed amounts. The billed amount (what the provider charges) is often higher but doesn't affect your costs in-network.
This is an educational estimate based on plan rules you enter. Always confirm with your insurer and plan documents. Actual costs may vary based on specific services, network status, and plan variations.
Yes—toggle to Family and set individual vs family deductibles and OOPs. The calculator handles both embedded (per-person) and aggregate (family-wide) deductible rules based on your plan structure.
If your plan has out-of-network coverage, enable it in the plan rules and set separate OON deductible, coinsurance, and OOP max. Note that balance billing (charges above allowed amounts) is not modeled here.
Contributions to HSA or FSA accounts are typically tax-deductible. The calculator estimates tax savings based on your marginal tax rate and eligible contributions (up to IRS limits).
A copay is a fixed amount you pay (e.g., $25 for a visit). Coinsurance is a percentage you pay after meeting your deductible (e.g., 20% of allowed amounts). Both count toward your OOP max.