Out-of-pocket cost calculator.
Your estimated cost.
How this calc works
Your insurance plan splits a medical bill into three buckets, in order:
- Deductible. You pay 100% of the allowed amount until you've met your deductible for the year.
- Coinsurance. After the deductible, you pay your coinsurance percentage (typically 20% for PPO, 30-40% for HDHP); insurance pays the rest.
- Out-of-pocket max. Once you've paid your OOP max for the year, in-network covered care is 100% paid by insurance — you owe nothing more.
The calc walks this exact sequence: if the allowed amount is $4,000 and you have $1,500 deductible remaining + 20% coinsurance + $6,000 OOP max remaining, you'd pay $1,500 (deductible) + 20% of the remaining $2,500 ($500 coinsurance) = $2,000. The OOP max only kicks in if your total would exceed it.
Where to find your numbers
- Cash price: Federally-mandated hospital price-transparency files (CMS rule, effective 2024+). Most hospitals publish a downloadable file; many have a consumer-friendly search tool too. Or ask the billing office for a self-pay quote.
- Allowed amount: Call your insurer with the CPT code for the procedure and ask for the in-network negotiated rate. Often 20-50% below cash price.
- Deductible, coinsurance, OOP max: Your insurer's member portal or the Summary of Benefits & Coverage (SBC) document. Mid-year, log in to see your remaining deductible and OOP-max balances.
When this calc is wrong
- Out-of-network providers. Different deductible, much higher coinsurance, and potential balance billing on top. Use the in-network vs out-of-network calculator instead.
- Surprise / emergency situations. The No Surprises Act limits what you can be billed; the calc shows the cost before NSA protections kick in.
- HSA / FSA-funded payments. The cost is the same; you're just paying with pre-tax dollars. See the HSA tax savings calc.
- Charity care or financial assistance. Many hospitals will reduce your bill if you ask; calc assumes you pay the negotiated amount.
Common questions.
Why is the cash price higher than the insurer allowed amount?
Hospitals set high "chargemaster" prices that insurance companies then negotiate down. The negotiated rate is what your insurance plan applies your deductible and coinsurance to — not the chargemaster price. Without insurance, you'd pay closer to the cash price unless you negotiate a self-pay discount.
What if I haven't met any of my deductible yet?
Plug in your full annual deductible as "remaining." You'll pay the deductible amount first, then coinsurance on the rest of the bill.
Does this work for dental?
Dental plans work differently — they typically have a low annual max ($1,000-2,000) instead of a high OOP max. This calc isn't built for dental; see the dental cost guide for cash prices and dental discount plans.
Is this the same as my insurer's cost estimator?
Most insurer tools use the same math but pre-fill the allowed amount based on your CPT code lookup. This calc is useful before you have a specific CPT or when you want to test "what if my deductible were higher?" scenarios.