Premiums are separate
Monthly premiums keep coverage active and do not count toward the out-of-pocket maximum.
Health Insurance Cost Calculator: Compare Premiums, Deductibles, Copays, and Out-of-Pocket Maximums US-first
Calculator inputs
Results
Lowest expected yearly cost
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Premiums + expected care
Lowest maximum exposure
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Annual premium + OOP max
Expected care cost
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For the lowest expected-cost plan
Insurer pays
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Estimated on allowed charges
Plan comparison
| Metric | Plan A | Plan B | Plan C | Plan D |
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Highlighted cells show the lowest expected yearly cost and lowest maximum exposure among visible plans. Worst-case yearly cost is annual premiums plus the out-of-pocket maximum; premiums are not included in the OOP maximum.
Best expected-cost plan breakdown
| Item | Amount |
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Flow: deductible to coinsurance to OOP max
| Care category | Allowed charges | Your raw share | Plan share after cap | Rule |
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Key Health Insurance Cost Rules
In-network matters
Deductibles, copays, coinsurance, and OOP caps usually work best for covered in-network care. Out-of-network rules can be very different.
Copay rules vary
Some copays apply before the deductible. Other services must satisfy the deductible before coinsurance begins.
Preventive care may be free
Many US plans cover eligible in-network preventive services at $0, but diagnostic add-ons can be billed differently.
Rx may have separate terms
Prescription tiers, specialty drugs, and separate drug deductibles can change the result materially.
Plan documents control
Use this calculator to compare assumptions. Your Summary of Benefits and Coverage, formulary, and insurer rules override estimates.
Methodology, Assumptions, and Sources
Last updated: June 29, 2026. Reviewed for accuracy: June 29, 2026.
Formula
For each plan, the calculator estimates expected yearly cost = annual premiums + expected member cost for covered care. Member cost is built service by service using copays, deductible, coinsurance, and the OOP maximum. Worst-case yearly cost is annual premiums + OOP maximum.
Assumptions
The default model assumes covered in-network care, annual plan-year limits, entered allowed costs, and no real-time subsidy or plan-price data. Out-of-network mode is conservative unless you choose to apply an OOP cap.
Limitations
Real plans may use referrals, prior authorization, separate tiers, balance billing protections, excluded services, drug formularies, family embedded limits, and local contracted rates that this simplified model cannot fully reproduce.
Source basis
Definitions and plan-selection concepts are based on HealthCare.gov guidance for premiums, deductibles, out-of-pocket maximums, Marketplace plan categories, cost-sharing reductions, and HSA-eligible plans. 2026 HDHP thresholds use IRS Rev. Proc. 2025-19. Marketplace subsidy context is cross-checked against KFF's Marketplace calculator notes.
- HealthCare.gov: out-of-pocket maximum
- HealthCare.gov: Bronze, Silver, Gold, and Platinum plan categories
- HealthCare.gov: income levels and Marketplace savings
- HealthCare.gov: cost-sharing reductions
- HealthCare.gov: HSA-eligible plans
- IRS Rev. Proc. 2025-19: 2026 HSA and HDHP limits
- KFF Health Insurance Marketplace Calculator
Worked Example: Deductible, Coinsurance, and OOP Max
Suppose a plan has a $1,500 deductible, 20% coinsurance, and a $5,000 out-of-pocket maximum. Premiums are separate from these medical cost-sharing rules.
| Stage | Example allowed bill | What you pay | Why |
|---|---|---|---|
| Before deductible | $800 office procedure | $800 | You pay covered allowed charges until the $1,500 deductible is met. |
| Finishing the deductible | Next $2,000 hospital bill | $700 + 20% of $1,300 = $960 | The first $700 completes the deductible; coinsurance applies to the remaining allowed amount. |
| After deductible | Later $1,000 imaging bill | $200 | With the deductible met, 20% coinsurance applies. |
| After OOP max | More covered in-network care | $0 for eligible services after $5,000 member spending | The plan pays covered in-network care after eligible deductible, copay, and coinsurance spending reaches the OOP maximum. |
Health Insurance Inputs - Plain-English Guide
This calculator is US-first because most health insurance search intent is about Marketplace and employer plan comparisons. You can still change the currency for non-US estimates, but the terminology and trust notes are based mainly on US plan design.
Premiums, deductible, coinsurance, and OOP maximum
The premium is the monthly amount you pay for coverage. The deductible is the first layer of eligible allowed charges you may pay before the plan shares costs. Coinsurance is your percentage after the deductible. The out-of-pocket maximum is the annual cap on eligible covered in-network medical spending, excluding premiums.
Allowed costs by service type
Allowed costs are the negotiated or plan-recognized amounts before insurance pays. Breaking expected use into primary care, specialists, urgent care, ER, labs, hospital care, and prescriptions makes the estimate clearer than putting all expected care into one bucket.
Marketplace context
State, ZIP, family size, age band, tobacco use, income, employer coverage, and metal tier can affect real plan prices and subsidy eligibility. This page does not quote real premiums or calculate official subsidies; use official Marketplace tools for exact eligibility.
Family and prescription rules
Family plans may have embedded or aggregate deductibles. Prescriptions may use separate deductibles, copays, coinsurance, or tiers. Use the advanced section to approximate those rules and check the plan's Summary of Benefits and Coverage for exact terms.
Health Insurance Cost FAQ
What is the difference between a premium and a deductible?
The premium is the monthly amount you pay to keep coverage active. The deductible is the amount of covered care you generally pay before the plan starts sharing costs, except for services covered before the deductible such as some preventive care or copay visits.
What is the difference between a copay and coinsurance?
A copay is a fixed amount for a service, such as a primary care visit. Coinsurance is a percentage of the allowed cost that you pay after the deductible or under another plan rule.
What counts toward the out-of-pocket maximum?
For covered in-network care, deductibles, copayments, and coinsurance usually count toward the out-of-pocket maximum. Premiums, non-covered services, out-of-network care, and amounts above the allowed charge generally do not.
Do premiums count toward the out-of-pocket maximum?
No. Premiums are separate from the out-of-pocket maximum, so this calculator shows worst-case yearly cost as annual premiums plus the plan out-of-pocket maximum.
How should I compare Bronze, Silver, Gold, and Platinum plans?
Compare total yearly cost, not just the premium. Bronze plans often have lower premiums and higher cost sharing, while Gold and Platinum plans usually have higher premiums and lower cost sharing. Silver plans can be especially important if Marketplace cost-sharing reductions apply.
When does a high-deductible health plan make sense?
A high-deductible plan may make sense when the premium savings are large, expected care is low, the worst-case exposure is affordable, and the plan is HSA-eligible. It can be a poor fit if frequent care makes the deductible likely.
How do family deductibles work?
Family plans may use embedded deductibles, where one person can meet an individual deductible, or aggregate deductibles, where the family deductible must be met before most cost sharing begins. Plan documents control the exact rule.
Can prescriptions have separate rules?
Yes. Many plans use prescription tiers, separate drug deductibles, or coinsurance for specialty drugs. This calculator includes separate prescription deductible and generic or brand copay fields for a simplified estimate.
Why can actual bills differ from this estimate?
Actual bills can differ because of network status, prior authorization, facility fees, bundled services, drug tiers, excluded care, balance billing rules, timing in the plan year, and local allowed amounts.
Are Marketplace subsidies included?
No automatic subsidy calculation is included. The Marketplace context section flags when premium tax credits or cost-sharing reductions may matter, but exact subsidies require an official Marketplace application or a data-backed subsidy calculator.