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Out-of-Pocket Maximum Calculator

Total cost of a health plan at expected and worst-case spend. The worst case, premium plus out of pocket maximum, is bounded and knowable, and it is the more useful number for choosing between plans.

Also called: health plan comparison, total healthcare cost calculator.

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Total cost at expected spend
$9,400.00

$9,400.00 at your expected spend of 5,000: 6,000 premium plus $3,400.00 of cost sharing. Your worst case is $15,000.00, reached at $33,000.00 of claims. The alternative plan costs $11,400.00 expected and $14,600.00 at worst. This plan is cheaper at your expected spend.

Cost sharing at expected spend
$3,400.00
Worst case total
$15,000.00
Claims needed to reach the maximum
$33,000.00
Alternative at expected spend
$11,400.00
Alternative worst case
$14,600.00
Spend at which the plans tie
$35,000.00
Which plan wins
This plan is cheaper at your expected spend.
How this is calculated

An estimate, not an offer or a guarantee. Projected returns assume the rate you entered holds for the whole term, which no market does.

Method and background

This is what the calculation gives for the numbers you entered. It is an estimate, not advice, and it knows nothing about your situation beyond those numbers. Rules for United States change on a published schedule; the effective date is shown on every rule-based tool.

How this is calculated

A plan costs the premium plus whatever cost sharing your claims trigger, capped at the out of pocket maximum. Comparing plans on premium alone ignores that a cheap plan with a high deductible can cost far more in a bad year. The worst case, premium plus maximum, is the figure that bounds the risk and is knowable in advance. The crossover spend shown is where the cheaper-premium plan stops winning, which is usually a lower number than people assume.

the worst case is bounded and knowable, which is the number a plan should be chosen on
OOP
Out of pocket maximum

Worked examples

Each of these is asserted on every build. If a change to the engine ever moved one of these answers, the build would fail before the page could print it.

a high deductible plan against a richer one

Annual premium
$6,000.00
Deductible
$3,000.00
Coinsurance
20%
Out of pocket maximum
$9,000.00
Expected medical spend
$5,000.00
Premium of the alternative plan
$9,600.00
Alternative deductible
$1,000.00
Alternative out of pocket maximum
$5,000.00

Total cost at expected spend$9,400.00

At 5,000 of claims you pay the 3,000 deductible plus 20% of the remaining 2,000, so 3,400. The worst case is the 6,000 premium plus the 9,000 cap. Reaching that cap takes 3,000 + 6,000/0.2 = 33,000 of claims. Worked by hand.

Open this example

no claims leaves only the premium

Annual premium
$6,000.00
Deductible
$3,000.00
Coinsurance
20%
Out of pocket maximum
$9,000.00
Expected medical spend
$0.00
Premium of the alternative plan
$9,600.00
Alternative deductible
$1,000.00
Alternative out of pocket maximum
$5,000.00

Total cost at expected spend$6,000.00

boundary: a healthy year costs exactly the premium, which is the case that makes the cheaper plan look right until the worst case is put beside it

Open this example

Method and limits

What it assumes

  • All claims are in network and count towards the maximum.

What it deliberately does not model

  • Out of network care often has a separate maximum or none at all.
  • Premiums may be paid pre-tax, which changes the comparison.
  • Provider networks and drug formularies differ between plans and matter more than the arithmetic.

Formula version 1.0.0 · definition 1.0.0 · United States · Report a problem with this calculator

Frequently asked questions

Which number should I compare plans on?
The worst case: premium plus out of pocket maximum. It is bounded and knowable, where expected spend is a guess, and it is the figure that tells you whether a bad year is survivable.