Health Insurance Out-of-Pocket Calculator
Understanding your health insurance cost-sharing structure helps you estimate total healthcare costs for the year. Your total cost has three layers: your annual premium (paid regardless of care), your deductible (paid first), and then coinsurance or copays until you hit your out-of-pocket maximum. Enter your plan details and estimated annual medical spending to see exactly what you will pay. The ACA out-of-pocket maximum for 2024 is $9,450 for individuals and $18,900 for families.
Out-of-pocket cost formula
OOP Costs = min(Deductible, Medical Costs) + min((Medical Costs - Deductible) x Coinsurance%, OOP Max - Deductible) + Copays
OOP Costs = min(OOP Costs, OOP Maximum)
Total Annual Cost = (Monthly Premium x 12) + OOP Costs
Once your total OOP spending (deductible + coinsurance + copays) reaches the OOP maximum, your plan covers 100% of covered in-network costs for the rest of the plan year. This is defined under the ACA at 42 U.S.C. 18022.
ACA cost-sharing limits (2024)
- Individual OOP maximum: $9,450
- Family OOP maximum: $18,900
- These limits apply to in-network, covered services only. Non-covered services and out-of-network costs may not count.
- Bronze plans typically have higher deductibles and lower premiums. Platinum plans have the opposite structure.
- High-Deductible Health Plans (HDHPs) for HSA eligibility in 2024: minimum deductible of $1,600 individual / $3,200 family.
Frequently asked questions
What is an out-of-pocket maximum?
The out-of-pocket maximum is the most you will pay for covered in-network healthcare services in a plan year. After you reach this limit, your insurer pays 100 percent of covered in-network costs for the rest of the year. For 2024, the ACA set the maximum out-of-pocket limit at $9,450 for an individual and $18,900 for a family.
What costs count toward my out-of-pocket maximum?
Under ACA rules, your deductible, copayments, and coinsurance for covered in-network services all count toward your out-of-pocket maximum. Monthly premiums do not count. Out-of-network costs generally do not count unless your plan specifies otherwise.
What is the difference between a deductible and coinsurance?
The deductible is a fixed annual amount you pay before your insurer starts sharing costs. Coinsurance is the percentage of costs you pay after the deductible is met. For example, with an 80/20 plan, your insurer pays 80 percent and you pay 20 percent of covered costs after your deductible until you hit your out-of-pocket maximum.
How does a copay differ from coinsurance?
A copay is a fixed dollar amount you pay per visit or service (for example, $30 per primary care visit), regardless of the total cost of that service. Coinsurance is a percentage of the total allowed cost. Many plans use copays for office visits and coinsurance for hospital care and procedures.
How do I choose between a high-deductible and low-deductible plan?
High-deductible health plans (HDHPs) have lower premiums but higher deductibles. They qualify you for a Health Savings Account (HSA). They are financially better if you are generally healthy and want to save on premiums. Low-deductible plans cost more per month but limit your exposure if you have significant medical needs.
Official sources
- Healthcare.gov: Out-of-Pocket Maximum Definition.
- CMS: 2024 Uniform Glossary of Health Coverage and Medical Terms.
- IRS: Publication 969: Health Savings Accounts and Other Tax-Favored Health Plans.
Reviewed by the CalculatorHub team, edited by James Graham, 14 June 2026. See our methodology.