MedicalBillCalc

Methodology & Sources

The calculator models one covered in-network claim where the deductible applies before percentage coinsurance and all modeled cost sharing counts toward the same out-of-pocket maximum. It uses the numbers you enter; the starting figures are hypothetical, not researched rates or plan terms. The billed amount is displayed but is not used to calculate the insured share.

Calculation

  1. Subtract the amount already met from the deductible. Apply the smaller of that remainder and the claim's allowed amount.
  2. Apply your coinsurance percentage to the allowed amount left after that deductible amount.
  3. Subtract the amount already counted from the out-of-pocket maximum. The estimated patient share is the smaller of this remainder and the deductible plus coinsurance calculated above.
  4. The estimated plan share is the allowed amount minus that patient share. Results are displayed to the nearest cent.

For example, with an $850 allowed amount, $1,500 of deductible remaining, and $6,000 left until the out-of-pocket maximum, the deductible applied to this claim is $850. There is no amount left for coinsurance, so the estimated patient share is $850, not $1,500.

Limits

This is not a quote, coverage determination, or bill. It does not model copayments, services exempt from the deductible, multiple claims, family versus individual accumulator rules, noncovered services, out-of-network balance bills, premiums, financial assistance, or other plan rules. Deductible and out-of-pocket accumulators must refer to the same relevant plan year and coverage category before the claim. Actual insurer processing and rounding may differ. Check the EOB and confirm with the insurer and provider.

When the insurance option is unchecked, the tool displays only the entered billed amount. It does not estimate self-pay discounts or how much a provider will accept.

Sources