Out-of-pocket max estimator

Understanding your out-of-pocket maximum

The out-of-pocket maximum is the most protective feature of any health insurance plan. Once you hit it, insurance pays 100% of covered costs for the rest of the plan year. But understanding how you get there — and what counts — makes the difference between planning well and getting surprised.

The three costs that count toward your OOP max

Three types of cost sharing accumulate toward your out-of-pocket maximum: your deductible (the amount you pay 100% before insurance shares costs), your coinsurance (the percentage you pay after the deductible, e.g. 20%), and copays for specific services. Each dollar you pay in any of these categories brings you closer to the maximum. Monthly premiums do not count — they are the cost of having coverage, not the cost of using it.

How to use this calculator

Enter your plan details — premium, deductible, coinsurance, and OOP max — then enter your best estimate of what you expect to spend on medical care this year. Use last year as a reference and adjust for any known procedures, prescriptions, or appointments. The calculator shows you your estimated out-of-pocket costs, what percentage of your OOP max you will likely reach, and whether you are projected to hit the limit entirely (at which point every further covered expense costs you nothing).

When hitting the OOP max changes your strategy

If this calculator shows you are likely to hit your out-of-pocket maximum, that changes your healthcare spending strategy. Any covered service you receive after hitting the maximum is free to you. That is the time to schedule elective procedures, stock up on prescriptions, or address deferred care — everything is covered until December 31st when your OOP max resets. If you have an HSA, funds contributed there can be used to cover costs while you work toward the maximum.