About the Health Insurance Cost Calculator
This health insurance cost calculator estimates what a health plan will really cost you in a year. It adds your share of the premiums to what you pay when you use care — the deductible, your coinsurance percentage on bills after the deductible, office-visit copays and prescription copays — and caps your spending at the plan’s out-of-pocket maximum, just as insurers do.
Use it to compare plans at open enrollment or on the Marketplace, to budget for a planned surgery or pregnancy, or to understand how much of a large bill your insurer would pay. The scenario chart shows three years side by side: a year with no care, your expected year, and a worst-case year where you reach the out-of-pocket maximum.
The calculation assumes in-network care and that copays count toward the out-of-pocket maximum, which is the rule for ACA-compliant plans. Enter your share of the premium (after any employer contribution or subsidy) for an accurate personal total.
With the default inputs, the total yearly cost is $7,280.00. Change any value above to recalculate instantly.
How to use the health insurance cost calculator
- 1Enter your share of the monthly premium.
- 2Enter the deductible, coinsurance and out-of-pocket maximum from the plan summary.
- 3Estimate the medical bills you expect that go through the deductible.
- 4Add office-visit copays, number of visits and monthly prescription copays.
- 5Compare the expected total with the worst case to judge the plan’s risk.
Formula and method
Your out-of-pocket cost is the copays for office visits and prescriptions plus your share of the other bills: the full amount up to the deductible D, then the coinsurance percentage c of everything above it. The sum can never exceed the out-of-pocket maximum; after that the plan pays 100% of covered in-network care for the rest of the year.
Adding twelve months of premiums gives the total yearly cost. The insurer’s share is the bills B minus the part you paid on them. The worst case — premiums plus the full out-of-pocket maximum — is the most you could spend on in-network covered care in a year.
- B
- Medical bills subject to the deductible
- D
- Yearly deductible
- c
- Coinsurance rate (your share after the deductible)
- Copays
- Office-visit copays × visits + monthly prescription copays × 12
Worked examples
Typical plan, $5,000 of bills
Copays are 8 × $30 + 12 × $20 = $480. On $5,000 of bills you pay the $2,000 deductible plus 20% of $3,000 = $2,600, so out-of-pocket is $3,080. Add $4,200 of premiums for a total of $7,280; the insurer pays $2,400 of the bills.
Light user with a richer plan
With only two office visits at a $25 copay, out-of-pocket is $50. Nearly all the cost is the $5,400 of premiums, giving $5,450 for the year — a sign a cheaper, higher-deductible plan may suit this person.
Surgery year: $50,000 in bills
The deductible plus 20% coinsurance on $48,000 would be $11,600, but the out-of-pocket maximum caps spending at $6,000 including $480 of copays. You pay $5,520 of the surgery bills and the insurer pays $44,480; with premiums the year costs $10,200.
Frequently asked questions
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 costs. The out-of-pocket maximum is the most you pay in a year for covered in-network care — deductible, coinsurance and copays combined. After you reach it, the plan pays 100%.
Do premiums count toward the out-of-pocket maximum?+
No. Premiums are paid regardless of whether you use care and never count toward the deductible or out-of-pocket maximum. That is why the total cost adds premiums on top of the capped out-of-pocket amount.
What is coinsurance?+
Coinsurance is your percentage share of a covered bill after the deductible is met. With 20% coinsurance on a $1,000 bill you pay $200 and the insurer pays $800, until you reach the out-of-pocket maximum.
Do copays count toward the deductible?+
Usually copays do not count toward the deductible, but on ACA-compliant plans they do count toward the out-of-pocket maximum. Some plans do apply the deductible first even to office visits, so check your Summary of Benefits and Coverage.
What is the highest out-of-pocket maximum allowed?+
For 2026 the ACA caps in-network out-of-pocket costs for Marketplace and most employer plans at $10,600 for an individual and $21,200 for a family. Many plans set lower maximums.
Results are estimates for educational purposes and are not financial advice. Rates, fees and terms vary — confirm with your lender or a licensed advisor before making decisions.