# Health insurance out-of-pocket cost calculator

Source: https://www.getprescience.com/tools/out-of-pocket-cost-calculator
Author: Rishab Jain, Cofounder and CEO, Prescience
Published: 2026-11-01
Updated: 2026-11-01
Cite as: Rishab Jain. "Health insurance out-of-pocket cost calculator." Prescience, November 1, 2026. https://www.getprescience.com/tools/out-of-pocket-cost-calculator

When a medical bill arrives, what you owe depends on three numbers: how much of your deductible is left, your coinsurance rate, and how far you are from your out-of-pocket maximum. You pay the bill up to your remaining deductible, then your share of the rest, and never more than the maximum for the year. Enter your plan's numbers and the bill to see your share and the plan's.

- **Order costs apply:** Deductible, then coinsurance
- **2026 ACA out-of-pocket limit:** $10,600 self / $21,200 family
- **2027 ACA out-of-pocket limit:** $12,000 self / $24,000 family
- **Common coinsurance:** 20% in network

## Estimate what you'll pay

_Interactive calculator: open the page in a browser to use it. The rules and figures it applies follow._

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](https://www.getprescience.com/guides/deductible-copay-coinsurance-explained).

## Worked examples

**A $12,000 hospital bill**

Illustrative. A plan with a $2,000 deductible (none of it used yet), 20% coinsurance and a $6,000 out-of-pocket maximum.

- Deductible: $2,000
- Coinsurance: 20% × $10,000 = $2,000
- You pay: $4,000
- Plan pays: $8,000

**You pay $4,000,** a third of the bill, and have $2,000 left before you reach the maximum.

**A $40,000 surgery**

Illustrative. The same plan, for a much larger bill.

- Deductible: $2,000
- Coinsurance before the cap: 20% × $38,000 = $7,600
- Out-of-pocket maximum: $6,000
- You pay: $6,000

**Capped at $6,000.** The plan pays $34,000, and anything else covered in network is free for the rest of the year.

**A $1,500 MRI early in the year**

Illustrative. The same plan, with the full deductible still to meet.

- Deductible left: $2,000
- You pay: $1,500
- Plan pays: $0

**You pay the whole bill.** It still counts toward your deductible, leaving $500 to go.

## Out-of-pocket limits for 2026 and 2027

**Annual limits on in-network cost sharing**

|  | 2026 | 2027 |
| --- | --- | --- |
| ACA limit, self-only | $10,600 | $12,000 |
| ACA limit, family | $21,200 | $24,000 |
| HSA-qualified HDHP limit, self-only | $8,500 | $8,700 |
| HSA-qualified HDHP limit, family | $17,000 | $17,400 |

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.

**Two family members with bills in the same year**

Illustrative. A family plan with a $2,000 individual and $4,000 family embedded deductible, 20% coinsurance and a $6,000 individual / $12,000 family out-of-pocket maximum. One child has a $5,000 bill and a parent has a $3,000 bill.

- Child: $2,000 + 20% × $3,000 = $2,600
- Parent: $2,000 + 20% × $1,000 = $2,200
- Family deductible met: $4,000 of $4,000
- Family total so far: $4,800

**$4,800 for the year so far.** With the family deductible met, everyone else in the family pays only coinsurance from here.

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](https://www.getprescience.com/tools/fsa-contribution-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.

> **Prescience Diamond: A company health plan with an effective $0 deductible.** Diamond shows the copay before each visit, so employees know their cost up front instead of working it out from an EOB.
> - **An effective $0 deductible** and simple copays shown before a visit
> - **A broad national PPO network,** plus providers we contract with directly
> - **24/7 physician-led care navigation** that books visits and explains costs
> - **Usually 10–20% below comparable fully insured coverage,** fixed in your quote, with no admin fees
> Best for teams of about 15 or more that want one great group plan. [Get a Diamond quote](https://www.getprescience.com/get-started?p=Employer&product=diamond)

**Choosing a company plan? Compare the actual employee costs**

Use your employee census to obtain a written proposal, then model its premium and covered cost-sharing. A household spending estimate is useful context, but it does not price the company plan.

[Compare plans for my team](https://www.getprescience.com/quote)

[Review the plan-design comparison](https://www.getprescience.com/guides/hdhp-vs-copay-plan)

## Frequently asked questions

**How do I calculate my out-of-pocket cost?**

Pay the bill up to your remaining deductible, then your coinsurance percentage on the rest. If that total would push you past your out-of-pocket maximum, you pay only up to the maximum.

**Does coinsurance count toward the out-of-pocket maximum?**

Yes. Deductibles, coinsurance and copays for covered in-network care all count. Premiums don't.

**What happens after I reach my out-of-pocket maximum?**

The plan pays 100% of covered in-network care for the rest of the plan year.

**What is the out-of-pocket maximum for 2026?**

The ACA limit is $10,600 for self-only and $21,200 for family coverage. Your plan's own maximum may be lower. In 2027 the ACA limit rises to $12,000 and $24,000.

**Do out-of-network costs count?**

Usually not, unless your plan says so or the No Surprises Act applies, such as for emergency care.

**What is the allowed amount?**

The price your plan has agreed to pay for a service. Your deductible and coinsurance are based on it, not on the provider's list price.

## Sources

- [DOL, ACA implementation FAQs Part 71, 2026 cost-sharing limits](https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-71)
- [CMS, 2027 premium adjustment percentage and maximum annual limitation on cost sharing (January 2026)](https://www.cms.gov/files/document/2027-papi-parameters-guidance-2026-01-29.pdf)
- [HealthCare.gov, Out-of-pocket maximum/limit](https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/)
- [HealthCare.gov, Coinsurance](https://www.healthcare.gov/glossary/co-insurance/)
- [CMS, No Surprises Act protections](https://www.cms.gov/nosurprises)
- [IRS Revenue Procedure 2025-19 (2026 HSA and HDHP limits)](https://www.irs.gov/pub/irs-drop/rp-25-19.pdf)