How do I calculate my out-of-pocket medical costs?

Your out-of-pocket cost depends on your insurance plan's deductible, coinsurance rate, copay, and out-of-pocket maximum. Use our calculator: enter your plan details and the procedures you need, and we'll calculate exactly what you'll owe.

What is the difference between a copay and coinsurance?

A copay is a fixed dollar amount you pay for a service (e.g., $30 for a doctor visit). Coinsurance is a percentage of the allowed amount you pay after meeting your deductible (e.g., 20% of a $5,000 surgery = $1,000).

What happens after I meet my out-of-pocket maximum?

Once you reach your out-of-pocket maximum (OOP max), your insurance pays 100% of covered services for the rest of the plan year. The 2026 ACA OOP max is $9,450 for individuals and $18,900 for families.

What Will I Actually Pay?

The only calculator that combines real procedure pricing with your insurance plan math. See your exact deductible, coinsurance, copay, and total out-of-pocket cost.

Search for Procedures

Add multiple procedures to calculate combined costs. Click a result to add it.

Your Insurance Details

Annual Deductible

Deductible Met So Far

Coinsurance (your %)

Out-of-Pocket Maximum

Copay per Visit

What do these mean?

Typical Bronze: $7,500 ded / 40% coins
Typical Silver: $4,500 ded / 30% coins
Typical Gold: $1,500 ded / 20% coins

Care Setting

🏧

Hospital Facility

Inpatient / ER

🏥

Hospital Outpatient

Same-day procedures

⚗

Surgery Center

ASC (often cheaper)

👥

Doctor's Office

Non-facility

Your Cost Breakdown

Add procedures and enter your insurance details, then click calculate.

Did You Know?

The average American pays $1,300/yr out-of-pocket
Same procedure: 2-5x price difference by setting
ASC saves 25-60% vs hospital outpatient
2026 ACA OOP max: $9,450 individual

Learn how insurance costs work →

Frequently Asked Questions

How accurate is this calculator?

Our calculations use real CMS Medicare 2026 fee schedule rates and actual ACA marketplace plan data from healthcare.gov. Commercial insurance typically pays 150-250% of Medicare rates. Your actual costs may vary based on your specific plan's negotiated rates with providers, which are not publicly available. This tool provides a well-informed estimate.

What is a deductible?

Your deductible is the amount you pay out of pocket before your insurance starts covering costs. For example, with a $2,000 deductible, you pay the first $2,000 of medical bills yourself. After that, your insurance kicks in and pays a percentage (based on your coinsurance rate).

Why does the same procedure cost different amounts in different settings?

Hospital outpatient departments have higher overhead and charge facility fees that ambulatory surgery centers (ASCs) and doctor's offices do not. Medicare pays different rates depending on where the procedure is performed. Getting an MRI at a freestanding imaging center can cost 40-60% less than at a hospital.

What ACA plan data do you have?

We have 4,044 real marketplace plans from the 2026 plan year across 30 states that use the federal exchange (healthcare.gov). This includes plan names, issuers, metal levels, premiums, deductibles, copays, coinsurance, and out-of-pocket maximums. Data is sourced from the CMS QHP Landscape file.