Health insurance out-of-pocket cost calculator

Estimate what you'll pay

Use the allowed amount, not the provider's list price. The allowed amount is the price your plan negotiated, shown on your explanation of benefits (EOB). An in-network provider can't bill you for the difference. Copays are left out; if your plan charges a copay for this service instead of coinsurance, you pay the copay.

How deductibles, coinsurance and out-of-pocket maximums work together

1. The deductible comes first Until you've paid your deductible for the year, you pay the full allowed amount for most services. Preventive care is covered at no cost before the deductible.
2. Then coinsurance After the deductible, you pay a percentage of each bill, often 20%, and the plan pays the rest.
3. The out-of-pocket maximum stops it Once your deductible, coinsurance and copays reach the maximum, the plan pays 100% of covered in-network care for the rest of the plan year.

Premiums don't count toward any of these. Neither do out-of-network bills on most plans, or services the plan doesn't cover. The full explanation, with definitions, is in our guide to deductibles, copays and coinsurance.

Worked examples

Out-of-pocket limits for 2026 and 2027

Most employer plans set their maximum well below these ceilings. On family plans, every person also has their own limit no higher than the self-only figure, so one family member's costs stop at $10,600 in 2026 even under a family plan with a $21,200 maximum.

Family plans: individual and family limits

On family coverage, there are usually two sets of numbers: an individual deductible and out-of-pocket maximum for each person, and a family total. How they interact decides what one person's bill costs.

• Embedded deductible: each person stops paying the full bill once they meet their individual deductible, even if the family total hasn't been met. Most PPOs and HMOs work this way.
• Aggregate deductible: nobody gets coinsurance until the family as a whole meets the family deductible. Common on HSA-qualified plans.
• Out-of-pocket maximum: under the ACA, no one person can pay more than the self-only limit ($10,600 in 2026) even on a family plan, so the individual maximum is always embedded.

To use the calculator for one person on a family plan, enter the smaller of what's left on their individual deductible and what's left on the family deductible, and the same for the out-of-pocket maximum.

Timing matters: deductibles reset every year

Deductibles and out-of-pocket maximums reset at the start of each plan year, usually January 1. That makes timing worth thinking about for planned care.

• If you've already hit your maximum this year, scheduling a planned procedure before the reset can make it free.
• If you're early in the year, a large bill now will use up the deductible and make the rest of the year's care cheaper.
• If your plan year and calendar year differ, check your summary of benefits; the reset follows the plan year.
• If you change jobs mid-year, amounts paid on the old plan usually don't count toward the new one.
• If you switch plans at open enrollment, your new deductible starts from zero on the first day of the new plan year, even with the same carrier.

Copays are the one cost the calculator leaves out. On most plans, copays count toward the out-of-pocket maximum but not the deductible, and you pay them even before the deductible is met for the services they apply to, such as office visits and generic drugs.

Getting a price before you get care

The calculator needs the allowed amount, and you can often get it before a visit instead of waiting for the bill. For planned care like an MRI, a colonoscopy that isn't preventive, or a surgery, a few minutes of checking can save hundreds of dollars, because prices for the same service vary widely between providers in the same plan's network.

1. Use your insurer's cost estimator Most carriers have a tool on their website or app that shows negotiated prices for common services by provider.
2. Ask for a good faith estimate If you're uninsured or paying yourself, providers must give you a written estimate for scheduled care under the No Surprises Act.
3. Ask for the billing codes For a planned procedure, ask the provider's office for the codes they'll bill, then look those up with your insurer.
4. Check where it's done The same MRI or surgery can cost several times more at a hospital outpatient department than at an independent imaging or surgery center.

Ways to lower a bill before you pay it

• Check the EOB first. Wait for the plan's explanation of benefits before paying a provider's bill, and make sure the amounts match.
• Ask for an itemized bill. Duplicate charges and services you didn't get are common on hospital bills.
• Use the No Surprises Act. Emergency care and many out-of-network bills at in-network facilities can only be charged at in-network cost sharing.
• Ask for a payment plan or financial assistance. Nonprofit hospitals must have financial assistance policies, often based on income.
• Pay with an HSA or FSA. Using pre-tax money cuts the real cost by your tax rate. See the FSA calculator.

Plans where this math is simpler

Deductibles and coinsurance are why medical bills are hard to predict. Diamond, our group plan, is built around an effective $0 deductible with copays employees can see before a visit, so employees rarely have to do this math.