How to use the out-of-pocket cost calculator
A U.S. health plan splits a medical bill in three stages: you pay the deductible first, then a coinsurance percentage of what is left, and everything stops once you reach the out-of-pocket maximum for the plan year. This calculator walks a single claim through all three stages, including amounts you have already met earlier in the year.
Enter the allowed charges the plan recognizes rather than the provider list price. The calculator applies the remaining deductible first, charges coinsurance on the balance, then caps your total at the out-of-pocket maximum you have left.
Basis and date — plan cost-sharing terms come from your Summary of Benefits and Coverage; the annual out-of-pocket maximum for non-grandfathered plans is limited each year by HHS under the Affordable Care Act. Figures here reflect September 2026 and change annually.
This tool is for general estimation only and does not guarantee what your plan will pay. Prior authorization rules, out-of-network balance billing, separate prescription-drug deductibles and non-covered services can change the result, so confirm any specific claim with your insurer.
Frequently asked questions
On most plans, yes. Deductible, copays and coinsurance you pay for covered in-network services usually count toward the out-of-pocket maximum, while premiums and non-covered services do not. Check your Summary of Benefits and Coverage for the exact rule.
Because the out-of-pocket maximum caps what you pay in a plan year. Once the remaining amount under that cap is reached, the plan pays 100% of allowed charges for covered in-network care.
The allowed amount is the negotiated price your plan recognizes for a service, not the provider list price. Out-of-network providers may bill you for the difference, which this calculator does not include.