Health Insurance Cost Estimator Educational
Inputs
Estimated Costs & Key Metrics
Line-by-line breakdown (education)
| Item | Amount |
|---|
Flow: deductible → coinsurance → OOP Max
| Step | Applied to | Your share | Plan share |
|---|
Formula: Total Annual Cost = Premiums + min(Copays + Deductible Portion + Coinsurance Portion, OOP Max).
When “Copays before deductible” is ON, copays are paid regardless of deductible status (but still respect OOP Max if selected). Otherwise, route services through deductible/coinsurance—enter allowed charges in the “Other/Hospital” fields.
How this health estimator works (plain English)
Your yearly cost has two parts: premiums you pay every month, and out-of-pocket you pay when you use care. The tool adds (1) annual premiums, and (2) your share of medical bills under the plan rules (copays, deductible, coinsurance), then caps your spend at the out-of-pocket maximum.
- Premiums: monthly × 12.
- Copays: fixed amounts per service (optionally apply before the deductible).
- Deductible: the first layer of allowed charges you pay 100%.
- Coinsurance: your % after the deductible.
- OOP Max: cap on your medical spending for covered, in-network services (excludes premiums).
Limitations: Simplified model. Real plans can have separate medical/Rx deductibles, tiered networks, per-service rules, facility fees, referrals/authorizations, and out-of-network benefits. Always check policy documents.
Health Insurance Inputs — Plain-English Guide (Educational)
This section explains every input used by the Health Insurance Cost Estimator so you can compare plans confidently. It’s educational and may use general terms found in the UK, US, and EU. Policies vary by provider and country, so always check your official plan documents. Nothing here is advice or a quote.
Currency & Premiums
Currency lets you view results in GBP (£), USD ($), or EUR (€) without changing the math. Monthly premium is what you pay each month to keep cover active (in the US this is your plan premium; in the UK it may resemble monthly contributions for private medical insurance alongside NHS access; in the EU it may complement statutory insurance). The tool multiplies the monthly amount by 12 to show an annual figure.
Deductible, Coinsurance, and Out-of-Pocket Maximum
The deductible is the first layer of eligible, in-network costs that you pay in full each year before most benefits share kicks in. After meeting the deductible, you usually pay a percentage called coinsurance (your share of the bill), while the plan pays the rest. Your medical spending is limited by the out-of-pocket maximum (OOP Max) — once your eligible payments in a year reach this cap, the insurer pays 100% of further covered, in-network costs for the remainder of the policy year. This cap does not include premiums.
Copays (Fixed Fees per Service)
Copays are flat fees for certain services: primary care (GP), specialist visits, urgent/ER care, and prescriptions. Some plans apply copays before the deductible (common for GP visits and generics), while other plans route those services through the deductible and coinsurance instead. The toggle “Copays apply before deductible?” controls this behavior. Another toggle, “Copays count toward OOP Max?”, reflects whether your copays help you reach the yearly spending cap.
Prescriptions (Rx)
Many plans use tiers. This tool simplifies tiers into generic and brand copays. Enter how many fills you expect over the year. In reality, some formularies use coinsurance for high-cost drugs or separate Rx deductibles; if that applies to you, model the extra cost under “Other allowed charges” as a conservative estimate.
Allowed Charges (Other & Hospital)
Allowed charges are the negotiated in-network rates set between the insurer and providers. Use Other allowed medical charges for items like imaging, labs, or day procedures, and Hospital/inpatient allowed charges for admissions or surgery. The estimator pushes these amounts through the deductible → coinsurance flow, then caps your spend at the OOP Max if applicable.
Visits & Utilization
The visit counters (GP/primary care, specialist, urgent/ER) and Rx fills turn into copay totals when “copays before deductible” is ON. If your plan routes these services through the deductible instead, keep the counters but set copays to 0 and reflect the expected billed amounts in the allowed-charges fields.
Network & Geography Notes
The calculator assumes in-network care. Out-of-network rules (common in the US), cross-border cover (EU), or private medical insurance alongside NHS (UK) may have different deductibles, coinsurance, or maximums. Always confirm: network participation, referral requirements, pre-authorizations, exclusions, and waiting periods.
What the Tool Shows
- Total annual cost: premiums + your medical spend (subject to OOP Max).
- Your medical spend: copays (if applicable) + deductible portion + coinsurance portion, capped by OOP Max.
- Insurer pays (estimate): the plan’s share of allowed charges after your portion is applied.
Important: Educational use only. Real policies can have separate medical vs Rx deductibles, tiered networks, facility fees, and country-specific regulations. Read your plan documents and consult your insurer or broker for exact terms.