Medical bill cost calculator: what will you pay on this bill?
Enter the allowed amount of a medical bill and the terms of up to three health plans. The calculator applies the deductible, copay, coinsurance and out-of-pocket maximum the way a plan does, then shows what you pay, what the plan pays, and what the year costs once the premium is counted.
Run one bill through three plans.
Pick the type of care, enter the allowed amount, and change any plan term to match your own. The result updates as you type. The three plans start with example numbers, so replace them with the figures from your Summary of Benefits and Coverage.
An estimate for planning, not a quote or a claim decision. Your plan documents and the carrier’s explanation of benefits control what you actually owe.
How a plan turns a bill into what you owe.
- Start with the allowed amount. Cost sharing is calculated on the contracted in-network rate, not the provider’s list price.
- Apply the deductible. You pay the allowed amount until the deductible is met. Money you already paid this year counts, so enter it if you have it.
- Apply the copay or coinsurance. A flat copay covers some services, such as office visits. Everything else shares the cost by percentage once the deductible is met.
- Stop at the out-of-pocket maximum. Deductible, copays and coinsurance add up to a ceiling. Past it, the plan pays covered in-network care in full.
- Add the premium and subtract employer dollars. The premium is paid whether or not you use care, and employer HSA or HRA dollars can pay part of the bill. Both change which plan costs least over the year.
Why the lowest premium is not always the lowest cost.
A plan with a higher premium and a lower deductible usually wins when a bill is large, and a plan with a lower premium and a higher deductible usually wins when care is light. The line chart above shows where those two cross for your numbers. To turn a yearly premium into a per-paycheck amount, use the payroll deduction calculator.
The rules behind the numbers.
The annual limit on cost sharing comes from Section 1302(c) of the Affordable Care Act, 42 U.S.C. 18022(c), and 45 CFR 156.130. Preventive care at no cost-sharing is required by 42 U.S.C. 300gg-13. HSA-eligible plan requirements are in Section 223 of the Internal Revenue Code.
The questions that come up when someone sees the result.
Ten plain answers about how a medical bill is shared between you and your plan.
What is the difference between a deductible and an out-of-pocket maximum?
The deductible is what you pay for covered care before the plan starts sharing the cost through coinsurance. The out-of-pocket maximum is the most you can pay in a plan year for covered in-network care, and it includes the deductible, copays and coinsurance. Once you reach it, the plan pays covered in-network care in full for the rest of the year.
In what order does a plan apply the deductible, copay and coinsurance?
It depends on the plan, which is why the calculator lets you set it. Many plans charge a flat copay for office visits before the deductible is met, then apply the deductible and coinsurance to everything else. Other plans, including most HSA-eligible plans, apply the deductible to nearly every service first. The Summary of Benefits and Coverage shows which rule your plan uses for each service.
Does the premium count toward the out-of-pocket maximum?
No. The premium is what you pay to have the coverage, and you owe it whether or not you use care. The out-of-pocket maximum counts only cost sharing on covered in-network care. That is why the calculator shows the premium separately and adds it back in to give a total cost for the year.
Do copays count toward the deductible?
On many plans they do not. A copay usually counts toward the out-of-pocket maximum but not toward the deductible, although some plans credit it to both. The calculator follows the more common rule and credits only deductible payments to the deductible. Check your plan documents if your numbers depend on the difference.
What is the difference between an embedded and an aggregate family deductible?
With an embedded deductible, each person has an individual limit inside the family deductible, so one member can reach the plan sharing in cost sharing without the whole family meeting the family amount. With an aggregate deductible, the plan starts sharing the cost only once the family total is met, and one person can satisfy all of it. Many HSA-eligible plans work this way, so the calculator lets you choose per plan.
Does each family member have their own out-of-pocket maximum?
Under the Affordable Care Act, the individual out-of-pocket limit applies to each person even when they are in family coverage, and the family limit caps the household total. So one member can reach the individual maximum and stop paying while others keep paying until the family limit is met. The calculator applies both limits when you choose family coverage.
Should I enter the billed charge or the allowed amount?
Enter the allowed amount, which is the contracted in-network rate shown on the explanation of benefits from the carrier. The billed charge is the provider list price and is usually higher. Cost sharing is calculated on the allowed amount, so using the billed charge overstates what you owe.
How do employer HSA or HRA dollars change what I pay?
Employer dollars placed in an HSA or HRA can pay part of a bill, so the calculator subtracts them from what you owe, up to the amount of the bill. Unspent HSA money stays yours and rolls over, so a plan with a larger deductible can cost less once those dollars are counted. HRA rules differ by plan, so confirm how yours reimburses.
What does this calculator not include?
It models in-network cost sharing for one bill. It does not model out-of-network care or balance billing, services the plan does not cover, separate prescription deductibles or tiers, prior authorization penalties, or the tax value of an HSA. Preventive care is covered at no cost in-network under federal law, so a preventive visit should cost nothing on any compliant plan.
Where do I find my plan’s numbers?
Start with the Summary of Benefits and Coverage, which your employer must provide and which lists the deductible, out-of-pocket maximum, coinsurance and copays in a standard format. The plan documents and the carrier’s member portal give the detail. If you are an employer comparing plan options for your team, we can run your real plans through this calculator and put the results in front of your employees.
Ready? Send us your renewal, or talk it through with someone first. No cost, no obligation.
General information about how health plan cost sharing works, not legal, tax or medical advice. Plan-specific questions belong with your carrier and plan documents.
Want your own plans run through this?
Book a 30-minute call and we will model your plan options on the bills your employees are most likely to see. Visit us at 41000 Woodward Avenue, Suite 350 East, Bloomfield Hills, MI 48304, or call 248.370.8853.
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