small business health insurance cost calculator

An official website of the United States government

Here's how you know

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

Start here Arrow Right

• Arrow Right See SHOP plans & prices
• Arrow Right Find an agent and broker
• Arrow Right See if you're eligible

How to enroll in SHOP insurance

Tools and calculators to help you apply, the shop fte calculator, the small business health care tax credit estimator, minimum participation rate (mpr) calculator, find local help.

• See SHOP plans and prices
• Calculates if your mix of full-time and part-time employees equals between 1-50 full-time equivalent (FTE) employees. Generally, only businesses with 1-50 FTEs are eligible for SHOP.
• A list of all your employees, both full-time (those working 30 or more hours per week) and part-time (working fewer than 30 hours per week)
• The number of hours worked per week by each part-time employee
• Number of employees who work at least 40 hours per week
• Number of hours worked by all part-time workers who work at least 120 days per year
• Total wages paid (the amount subject to Social Security and Medicare tax)
• Total amount of health insurance premiums you pay for your employees
• Helps predict if you’ll meet the MPR required to enroll in the SHOP coverage (in most states, at least 70% of employees must accept their insurance offer before the group can enroll)
• State where your main business office is located
• Number of employees accepting coverage
• Number of employees not accepting your SHOP coverage offer who don’t have other kinds of health coverage
• Number of employees not accepting your SHOP coverage offer who are covered by other insurance (like another job plan, a spouse’s or another person’s coverage, COBRA, the individual and family Health Insurance Marketplace ® , Medicare, Medicaid, veterans coverage, Indian Health Service coverage, or TRICARE).
• Find an agent or broker in your area who’s licensed and registered to sell SHOP insurance
• They can advise you on your coverage options, help you enroll and answer your coverage questions

See plans and prices

• Use the link below and enter information about your business for a custom cost estimate.
• This tool lists all available SHOP plans in your area. If there are no SHOP plans in your area, you may also be able to get qualified small group health coverage outside of SHOP through an insurance company or an agent or broker. Visit  find.healthcare.gov  to see what private health plans outside of the SHOP may be available to you.
• Contact the SHOP Call Center at 1-800-706-7893 (TTY: 1-888-201-6445).

• Credit cards
• View all credit cards
• Banking guide
• Loans guide
• Insurance guide
• Personal finance
• View all personal finance
• Small business
• View all small business

You’re our first priority. Every time.

We believe everyone should be able to make financial decisions with confidence. And while our site doesn’t feature every company or financial product available on the market, we’re proud that the guidance we offer, the information we provide and the tools we create are objective, independent, straightforward — and free.

So how do we make money? Our partners compensate us. This may influence which products we review and write about (and where those products appear on the site), but it in no way affects our recommendations or advice, which are grounded in thousands of hours of research. Our partners cannot pay us to guarantee favorable reviews of their products or services. Here is a list of our partners .

How Much Does Small-Business Health Insurance Cost?

Many or all of the products featured here are from our partners who compensate us. This may influence which products we write about and where and how the product appears on a page. However, this does not influence our evaluations. Our opinions are our own. Here is a list of our partners and here's how we make money .

⏰ Estimated read time: 6 minutes

• $7,813 for single coverage, of which employers contributed $6,485 , or 83%.
• $21,804 for family coverage, of which employers contributed $13,737 , or 63%.

at Tivly.com

How does small-group health insurance work?

How much do group health insurance premiums cost employers, employer contribution requirements, employee profile.

• The age of your employees and their dependents.
• Employees’ tobacco usage habits.
• Where your employees live.

The type of plan you pick

Industry and location, where can you buy small-group health insurance.

• Directly from an insurance provider in your state.
• Using an insurance broker. The broker will shop for policies tailored to your business. They’ll charge a commission (typically a percentage of the premium), and may also charge a broker’s fee. Some payroll products, such as Gusto and QuickBooks Payroll , allow you to buy health insurance from brokers on their platforms.
• Using the Small Business Health Options Program: SHOP is the federal government's insurance option for businesses with fewer than 50 full-time equivalent employees (up to 100 in some states). Most states require at least 70% of your eligible employees to participate in the SHOP health plan you offer.Businesses with fewer than 25 employees may qualify for a small-business health care tax credit worth up to 50% of premium costs.
• Using a Professional Employer Organization. A PEO is a company you can hire to administer benefits on your behalf. PEOs can legally become the co-employer of your employees. By serving as co-employer for multiple small companies, PEOs have a combined employee pool equivalent to that of a larger company. This gives them access to more competitive insurance rates than small businesses can typically get on their own.
• Qualify for QSEHRA . This is an arrangement for small businesses that offers employee reimbursement for qualified health expenses. Employees are not allowed to contribute through their paychecks and employer contribution terms to each employee’s QSEHRA must be the same.

Business Owner’s Policy (BOP): What It Covers, How to Get It

What Is Workers’ Compensation?

LLC Insurance: Best Options for Your Business in 2023

Dive even deeper in Small Business

Best small-business insurance 2023: compare companies and coverage, how to get business insurance: the ultimate 4-step guide, how much does business insurance cost.

Grow your small business with tailored insights, recommendations, and expert content.

To help you estimate your potential tax credit amount, input the data into the calculator to determine your estimated potential health insurance savings under the new health reform law. This tool is provided for your convenience and education concerning the small employer's tax credit. This tool is not intended to provide tax or legal advice, and you should not rely on the information provided without first consulting a tax professional regarding the final amount, and any questions you have relating to your unique circumstances. The tool provides an approximation of the tax credit based on the questions answered, the data provided, and the information currently available to the public from the IRS regarding the tax credit. A more detailed analysis by a tax professional may result in a different amount or might result in no credit.

• Must not employ more than 25 full-time equivalent (FTE) employees for the taxable year,
• Must cover at least 50 percent of the cost of health care coverage for certain workers based on the single rate.
• The average annual compensation of those employees must not exceed $50,000 per employee per year,
• Must maintain a qualifying arrangement.

In 2010, the maximum tax credit is 35% of employer-paid premiums; for tax-exempt organizations the maximum is 25% of premiums-paid.

Small businesses can claim the credit when they file their 2010 income tax return in 2011. Additional information will be posted to the IRS website when available.

• Estimate Your Tax Credit
• Bookmark/Share
• Frequently Asked Questions
• Member Services
• Rights & Resources
• Legal Notices
• Web Privacy Statement
• Investor Information
• Aetna Foundation
• Health Care Reform

Tools for Employers and Organizations

• Find a Doctor or Hospital
• Find a Document or Form
• Manage your Plan
• Get a Report
• Contact an Agent

Plans and Benefits

• Buy Health Insurance
• Buy Dental Insurance
• Federal Employees
• Medicare Insurance
• Aetna International
• All Plans & Benefits
• Privacy Information
• Legal Statement
• Program Provisions
• Member Disclosure
• Aetna Companies: State Directory

Understanding Small Business Health Insurance Costs

• Small Business Plans

What Is The Average Cost Of Small Business Insurance?

The cost of small business health insurance, also known as small group health insurance, will depend on the type of plan or plans provided by your business. As a small business owner, you will need to think of how much coverage is needed for your employees. Consider premiums, out-of-pocket costs, and provider networks when comparing plans.

What Are The Individual Costs To Consider For Group Health Insurance?

Premiums: Premiums are the monthly payments for health insurance coverage. Higher premiums provide more coverage for some plans. As a small business owner, you typically pay at least 50% of the premium for your employees. Paying half also allows your business to claim the federal government small-business healthcare tax credit.

Network: Some plans require employees to use doctors in their network or pay more for out-of-network providers.

Out-of-pocket costs: Out-of-pocket costs for employees include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.

How Do Group Health Insurance Plans Differ In Cost From Individual Plans?

Group health insurance plans are evaluated by looking at the total group of employees in your company covered under the plan. With group health insurance, an employer pays all or part of the monthly premiums for the plan.

How Much Does Small Business Health Insurance Cost Per Employee?

A few factors affect what you will pay per employee for group health insurance. To calculate health insurance for your company, you need to determine the following:

Employee premium contributions

How much your employees contribute to monthly premiums affects the overall cost of health insurance for your business. As a small business owner, you may want to contribute more than half for group health insurance as an incentive for employee recruitment and retention.

Amount of coverage

As a small employer, you may want to include coverage specific to your industry, such as coverage for risk-related injuries and illnesses to protect against medical liability. Consider the age of the employees being covered and where they are located when it comes time to compare the cost of group insurance health plans.

Tax credits

Under the Affordable Care Act, employers who have fewer than 25 full-time employees, who pay average wages of $56,000 or less, or who cover at least half of their employees’ premiums are eligible for tax credits for their small group health insurance plans. These credits can help lower the cost of your  small business health insurance .

Find Small Group Health Insurance That Fits Your Business

Compare health insurance plans and find one that works for your business and your employees.

Related Articles 

How does small business health insurance work.

Understand the basics of small business health insurance and what you need to know to choose a plan for your business.

How To Choose Small Business Health Insurance Plans

Explore available small business health insurance plan options to find the best coverage that fits your company.

Small Business Requirements For Health Insurance

Understand the eligibility requirements for small business health insurance coverage and see if your business qualifies.

Not connected with or endorsed by the U.S. Government or the federal Medicare program.

The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent or insurance company. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, please contact your agent or the health plan.

Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Call our Customer Service number, (TTY: 711). 

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a nuestro número de Servicio de Atención al Cliente (TTY: 711).

 注意：如 果您使用非英語的其他語言，您可以免費獲得語言援助服務。請致電聯絡客戶服務部（聽語 障用戶請致電：711）。

The independent source for health policy research, polling, and news.

Health Insurance Marketplace Calculator

Estimate health insurance premiums and subsidies for health insurance coverage through marketplaces.

Published: Oct 27, 2023

About this tool

The Health Insurance Marketplace Calculator provides estimates of health insurance premiums and subsidies for people purchasing insurance on their own in health insurance exchanges (or “Marketplaces”) created by the Affordable Care Act (ACA). With this calculator, you can enter your income, age, and family size to estimate your eligibility for subsidies and how much you could spend on health insurance. You can also use this tool to estimate your eligibility for Medicaid. As eligibility requirements may vary by state, please contact your state’s Medicaid office or Marketplace with enrollment questions. We encourage other organizations to feature the calculator on their websites using the embed instructions .

Enter Information About Your Household

1. select a state .

Enter your zip code

Your county is .

Select county

2. Enter yearly household income as...

3. is coverage available from your or your spouse’s job , 4. number of people in family , 5. which members of your family are enrolling in marketplace coverage , 5. number of adults (21 to 64) enrolling in marketplace coverage , 6. number of children (20 and younger) enrolling in marketplace coverage, 7. have you received or were you approved to receive unemployment compensation at any point in 2023 .

The Health Insurance Marketplace Calculator is based on the Affordable Care Act (ACA) as signed into law in 2010, and subsequent regulations issued by Health and Human Services (HHS) and the Internal Revenue Service (IRS).

Premiums displayed in the calculator’s results are based on actual exchange premiums in 2024 dollars. Premiums were obtained through data published by the Centers for Medicare and Medicaid Services (CMS) , data received directly from state exchanges or insurance departments, and data collected from state-based exchanges by KFF researchers. The silver premium is the second-lowest cost silver premium available in the county of the entered zip code and the bronze premium shown is the lowest-cost bronze plan in the county of the entered zip code. Not all plans are available in all parts of the county, so actual premiums may vary depending on plan availability. Premiums shown are the premium portion used for Essential Health Benefits. Actual premiums may be higher if plans include "non-essential benefits" such as dental or vision care.

The premium is adjusted for family size and age of the user. Premiums in the calculator vary by age within the three to one limit specified in the law, using age factors from proposed regulations issued by HHS (or, state specific age factors where states have adopted them). The calculator does not display a tobacco surcharge. However, in most states, insurers can charge a tobacco surcharge of up to 50% of your total premium, and tax credits do not apply to the surcharge. Actual tobacco surcharges will vary by plan and some states do not permit insurers to vary premiums by tobacco status .

Frequently Asked Questions

If you have questions about how the health reform law will affect you and your insurance options, please go to HealthCare.gov, or contact their Help Center at 1-800-318-2596 if you have questions that cannot be answered on their website. You can also contact your state’s Consumer Assistance Program , Exchange, or Medicaid office with questions about eligibility and enrollment. To find help from Navigators and other certified assisters in HealthCare.gov states, click here .

KFF is not able to provide individual advice on your insurance options. However, we do provide answers to a number of frequently asked questions below, along with more detailed questions and answers in our Health Reform FAQ page.

I am having difficulty viewing or understanding my results. What should I do?

It could be that you are using an older version of Microsoft Edge or Firefox. Try updating to a newer version of your web browser. Not sure which browser version you are running? Check here for Microsoft Edge  or here for Firefox . If you continue to have technical problems with the Calculator after updating your browser, please contact KFF.

Please note that we are not able to provide individual advice or assistance understanding your results. If you have additional questions, we suggest that you contact Healthcare.gov or your state’s Health Insurance Marketplace for more information.

Has the calculator been updated for 2024?

Yes, the calculator now shows premiums for 2024 in all states.

Does the calculator provide definitive results for what I will pay?

No. The calculator is intended to show you an  estimate  of how much you may pay and the amount of financial help you may be eligible for if you buy coverage through the Health Insurance Marketplace. To find out if you are eligible for financial assistance and to sign up, you must contact HealthCare.gov, your state’s Health Insurance Marketplace, or Medicaid program office.  

Although the Health Insurance Marketplace Calculator is based on actual premiums for plans sold in your area, there are several reasons why your calculator results may not match your actual tax credit amount. For example, the calculator relies completely on information as you enter it, whereas the Marketplace may calculate your Modified Adjusted Gross Income (MAGI) to be a different amount or may verify your income against previous year’s data.  

Has the calculator been updated for the changes enacted through the Inflation Reduction Act (IRA) ? 

Yes, t he calculator estimate s  how much you may pay and the amount of financial assistance you will receive under the Inflation Reduction Act (IRA), which continued expanded amounts and eligibility for Marketplace subsidies.

How do health insurance subsidies work?

Subsidies are financial assistance from the Federal government to help you pay for health coverage or care. The amount of assistance you get is determined by your income and family size. There are two types of health insurance subsidies available through the Marketplace: the premium tax credit and the cost-sharing subsidy .

The premium tax credit helps lower your monthly  premium  expenses. This subsidy is available to people with family incomes 100% of the poverty level or greater who buy coverage through the Health Insurance Marketplace. These individuals and families will pay between 0% and 8 . 5 % of their incomes for a mid-level plan premium (the "benchmark silver plan").  Anything above that is paid by the government. The amount of your tax credit is based on the price of the benchmark silver plan in your area, but you can use your premium tax credit to purchase any Marketplace plan, including Bronze, Gold, and Platinum plans (these different types of plans are described below). You can choose to have your tax credit paid directly to the insurance company so that you pay less each month, or, you can decide to wait to get the tax credit in a lump sum when you do your taxes next year.  KFF FAQs provide additional information about  how premium tax credits work .  

Cost-sharing subsidies (also called “cost-sharing reductions”) help you with your costs when you use health care, like going to the doctor or having a hospital stay. These subsidies are only available to people purchasing their own insurance who are eligible to receive a premium tax credit and make between 100% and 250% of the poverty level . If you qualify for a cost-sharing subsidy, you would need to sign up for a silver plan to take advantage of it. Unlike the premium tax credit (which can be used for other “metal levels”), cost-sharing subsidies only work with silver plans. With a cost-sharing subsidy, you still pay the same low monthly rate of a silver plan, but you also pay less when you go to the doctor or have a hospital stay than you otherwise would. (Enhanced cost sharing subsidies are available for Native Americans at somewhat higher income levels under any Marketplace plan.)

For more information, read the actuarial value question below. If you have more specific questions about your subsidy, you can consult our FAQ pages or contact an assister or navigator through Healthcare.gov or your state’s Marketplace.

What is included in household income? How do I know what to enter for my income?

The Health Insurance Marketplace Calculator allows you to enter household income in terms of 2024  dollars or as a percent of the Federal poverty level.  Household income  includes incomes of the person who pays taxes, the spouse, and , in some cases,  children, known as dependents on tax returns. For the purposes of the calculator, you should enter your best guess of what your income will be in 20 24 .  

When you go to HealthCare.gov or your state’s Health Insurance Marketplace website, it will walk you through the steps to calculate your household income based on wages, interest, dividends, Social Security, and certain other income sources. Eligibility for premium tax credits is based on your  household’s  Modified Adjusted Gross Income, or MAGI.  Your most recent tax return will show your   A djusted  G ross  I ncome  (AGI) .  For many people, MAGI is the same or very close to adjusted gross income.  MAGI modifies your  A djusted  G ross  I ncome by adding any non-taxable Social Security benefits you  may  receive, any tax-exempt interest you  may  earn, and any foreign income you earned that was excluded from your income for tax purposes.  The calculation does not include income from gifts, inheritance , supplemental security income (SSI),  and some other income sources. For more information, see   here .  

What is the Federal poverty level?

The Federal poverty level varies by family size. For Marketplace coverage in 2024 , the poverty level used is $14,580 for a single adult and $30,000  for a family of 4. Federal poverty level is higher for Alaska and Hawaii.

What is Medicaid? How does it relate to financial help through the Health Insurance Marketplace?

Medicaid is a  comprehensive, free  health insurance program (offered through a partnership between states and the Federal government) for people wh en they  have limited income .   Eligibility for Medicaid is based on your current income (vs eligibility for marketplace subsidies, which is based on your estimated total annual income for 2024).  Medicaid programs vary from state to state, but most health care services are covered at little or no cost and no premium is charged. If you are eligible for Medicaid, then you would not be eligible for subsidies in the Marketplace and would instead need to sign up for Medicaid.  

As a result of the  ACA , states have the option to expand Medicaid eligibility to  adults with incomes up to 138% of the poverty level. (Children in households with even higher income are eligible for Medicaid or the Children’s Health Insurance Program (CHIP) in every state.)   Currently , 41 states (including DC) have adopted the Medicaid expansion and 10 states have no t done so . If you  are an adult living  in a state that has not expanded Medicaid and you expect your income to be  at least as high as the poverty level, then you may be eligible for subsidies through HealthCare.gov .  If you expect that your income next year will be below the poverty level, then you may not be eligible for assistance through the Marketplace. However, it is possible that you may still qualify for Medicaid under your state’s eligibility criteria, particularly if your income is very limited and you have children, are pregnant, or have a disability.  

The Health Insurance Marketplace Calculator takes into account whether or not your state has decided to expand Medicaid, so you can use this tool to estimate your eligibility for Medicaid. Again, keep in mind that – even if your state did not expand Medicaid – you or some members of your family may still be eligible for Medicaid. To find out if you qualify for Medicaid, contact HealthCare.gov, your state’s Marketplace, or your state’s Medicaid program office for information about eligibility and enrollment.

If I am eligible for Medicare, can I still sign up on the Marketplace?

No, you cannot sign up for  new  Marketplace coverage if you are eligible for Medicare.  Most people age 65 and older are eligible for Medicare, which is health insurance program run by the federal government.  If you are eligible for Medicare, even if you did not choose to enroll in Medicare, you would not be able to purchase Marketplace coverage.  

When using the Health Insurance Marketplace Calculator, if some members of your household are eligible for Medicare and others are not, you should enter your full household size (including those who are eligible for Medicare) in Question #4. For the following question (#5), please enter only those family members who are signing up for Marketplace coverage (do not enter adults who are eligible for Medicare in Question #6).

If you are over the age of 65 but not yet eligible for Medicare due to immigration status or your work history, you may be eligible for Marketplace coverage and subsidies. You can use the Health Insurance Marketplace Calculator by entering your age as 64.

Does my age or health status affect how much I pay for health insurance?

As a result of the  ACA , insurance companies cannot deny you coverage or make you pay more for your health coverage based on your health.  

In most states, older people will still pay more for health insurance than a younger person. The  ACA requires that people aged 64 and older can be charged no more than 3 times that of a 21-year-old. Children under age 21 have slightly lower premiums and families with more than three children under the age of 21 will be charged premiums for no more than three children.  

Vermont and New York are currently the only states that  prohibit age-rating; in these states, plans charge the same premium for adults regardless of age.   If you live in one of these states, the Health Insurance Marketplace Calculator will calculate your premiums according to your state’s rules.  

Does where I live affect how much I pay for health insurance?

Yes. The cost of health insurance (your monthly premium) varies quite a bit by state, and even within regions of a state. This is because of several factors, such as the cost of living and cost of health care services in your area.

Your premium tax credit is tied to the cost of insurance in your area. If you live in a high-cost area, you may be eligible for more financial assistance.

Premiums in the Health Insurance Marketplace Calculator are actual premiums in your area. It is possible that some plans may not be available in your particular zip code or county, though. For this reason, you may get slightly different results when you apply for subsidies through HealthCare.gov or your state’s Marketplace.

If I use tobacco, can this affect how much I pay for health insurance?

Yes, in most states, insurers can charge people who use tobacco a higher premium (this is called a “tobacco surcharge”).  Currently, only six states (California, Massachusetts, New Jersey, New York, Rhode Island, and Vermont) and the District of Columbia do not allow private health plans to charge higher premiums for people who use tobacco ;   and  several other states  limit tobacco surcharges to less than 50%.    

Under the  ACA , private insurers can charge tobacco users no more than 50% more per month than those who do not use tobacco. The health law also makes clear that financial help through the Health Insurance Marketplace cannot be used to cover the portion of the premium that is due to a tobacco surcharge.  

The Health Insurance Marketplace Calculator does not adjust your results based on tobacco use because tobacco surcharges vary quite a bit from plan to plan. Even in states that allow it, some insurers choose not to charge higher prices for tobacco users or charge relatively low surcharges. For this reason, the calculator warns you when you might face higher prices, but to find out your true costs, you will need to go to HealthCare.gov or your state’s Marketplace.

What are Bronze and Silver plans?

When you buy coverage through the Health Insurance Marketplace you can choose between four levels of coverage: Bronze, Silver, Gold, and Platinum. The levels are based on how much financial protection the plans offer you when you get sick or need medical care and how much you will have to pay out-of-pocket for care subject to the plan deductible and other cost sharing.

Bronze plans will have the lowest monthly premiums, but  have the highest deductibles, copayments, and other cost sharing. I f you get sick or have an accident, your share of  covered medical bills that you will have to pay out-of-pocket will be higher because of the higher cost sharing. Silver plans are more protective and will have higher monthly  premiums , but  generally have somewhat  lower deductibles and other cost sharing, meaning you would likely spend less  out of pocket  when you get medical care. Gold and platinum plans have the highest monthly payments, but  the lowest cost sharing, leaving you with  fewer additional costs  to pay for covered services .  

The Health Insurance Marketplace Calculator shows the cost of silver and bronze plans in your area. Silver plans are important because these are used as a “benchmark” for calculating how much assistance you are eligible for. The silver premium shown in the calculator is the second-lowest-cost silver plan in your area.

The Health Insurance Marketplace Calculator will also show you the price of the lowest-cost bronze plan in your area. Bronze plans are the lowest level of coverage that most people are required to have under the health law. If a Bronze plan is still unaffordable to you even after financial assistance, or if you are under the age of 30, you may purchase a catastrophic plan. The calculator will tell you when catastrophic coverage may be an option to you.  Premium tax credits cannot be applied to catastrophic health plans.  

For more information on the difference between bronze and silver plans, see the question on actuarial value, below.

What are my options if I have job-based health coverage?

With most job-based health plans, an employer pays part of your monthly or yearly costs (premiums). In general, people who qualify for health insurance through their job are not able to get financial assistance through the Marketplaces.

However, if your employer’s coverage is either  unaffordable  or doesn’t meet the health care law’s “ minimum value ” requirement, then you may be eligible for financial help to purchase through the Marketplace. “Minimum value” means your employer plan pays at least 60% of the total cost of medical services. Your employer can tell you whether the insurance plan it offers meets minimum value.  It also can provide you with information to determine if the plan is considered affordable to you.  

Family members (spouses and children) who are eligible for employer-sponsored coverage can still qualify for Marketplace premium tax credits if the employer-sponsored coverage is considered unaffordable. Starting in 2023, the so-called “ Family Glitch ” has been fixed to allow family members in these circumstances to enroll in subsidized coverage.

When using the Health Insurance Marketplace Calculator, you can answer “No” to Question #3 if your employer’s coverage is unaffordable or does not meet the minimum value requirement.

What is actuarial value and how does it affect how much I pay for insurance and health care?

While health insurance may pay for most of a covered medical service, you generally still pay some of the cost when you go to the doctor or have a hospital stay.  Actuarial value is the percentage of total covered medical expenses that are paid for by the insurance company, on average, for a typical population. The higher the actuarial value, the more financial protection the plan is likely to offer you when you get sick or need medical care.  

For example, if a plan has an actuarial value of 70%, then the insurance company will pay about 70% of the total medical expenses  for everyone covered by that plan . Together, you and everyone enrolled in the plan would pay the remaining 30% of the total bills. This  does not   mean  that you personally will pay 30% of your expenses. Rather, this is an average across everyone enrolled in the plan. Your own costs will vary substantially from this amount, depending on how much care you use.  

While actuarial value doesn’t tell you exactly what you will pay, understanding it can help you pick which level of plan is right for your health needs. Bronze plans,  which are the lowest level of coverage offered through the marketplace,   have an actuarial value of about 60%.  Bronze  plans will have low monthly premiums, but if you get sick or have an accident you will pay more in medical bills.  Silver  plans are  somewhat  more financially protective and have an actuarial value of about 70%.  Gold  and  Platinum  plans have the highest monthly payments but also are the most protective if you get sick or need a lot of medical care: they have actuarial values of about 80% and 90%, respectively. Once you pick which level  of coverage is right for you, you can compare plans of a similar value side-by-side.  

If your income is between 100% and 250% of the federal poverty level, you may qualify for a  cost-sharing subsidy  if you sign up for a silver plan (these subsidies are explained more above). With a cost - sharing subsidy, you still pay the same low premium of a silver plan, but  the plan will be modified to reduce deductibles and other cost sharing to levels more similar to those found in gold or platinum plans.  Normally silver plans have an actuarial value of 70%, but with the cost-sharing subsidy, your silver plans’ actuarial value will range from 73% to 94% (depending on your income).  This means you will likely pay less when you go to the doctor or hospital than you otherwise would with a silver plan.  

The Health Insurance Marketplace Calculator estimates whether you may be eligible for cost sharing subsidies. If you are likely eligible for a cost sharing subsidy, the calculator also shows what your silver plan’s actuarial value would be.

Previous Versions of the Calculator

2023 Calculator 2023 Calculadora del Mercado de Seguros Médicos 2022 Calculator 2022 Calculadora del Mercado de Seguros Médicos 2021 Calculator 2021 Calculadora del Mercado de Seguros Médicos 2020 Calculator 2020 Calculadora del Mercado de Seguros Médicos 2019 Calculator 2019 Calculadora del Mercado de Seguros Médicos 2018 Calculator 2018 Calculadora del Mercado de Seguros Médicos 2017 Calculator 2016 Calculator 2015 Calculator 2014 Calculator

Other Versions Of Calculator

• Understanding the Health Insurance Marketplaces
• Calculadora del Mercado de Seguros Médicos
• Explaining Health Care Reform: Questions About Health Insurance Subsidies
• What to Watch in the 2024 ACA Open Enrollment
• Signing Up for Marketplace Coverage Remains a Challenge for Many Consumers
• FAQs: Health Insurance Marketplace and the ACA

How to save money on small business health insurance

Business Insider said many small business owners want to offer health insurance but can’t afford to do so. Understandably, paying a monthly premium for each employee as a start-up or small business employer is costly. To help you with that, here are some tips for how you can save money on health insurance.

• Raise the pre-agreed amount that your employee should pay the insurer in the event of a claim.
• Lower the cover on outpatient medical services of your employee’s insurance.
• Avoid overpriced health care facilities and private hospitals.
• Shop around, do not stick to one single insurer or policy tier, and look for discounts offered by different UK health insurance companies.
• Save yourself and your employees from out-of-pocket costs by providing a variety of health plans for each worker.
• Educate your employees on the importance, cost, and terms of getting health insurance.
• Pre-tax and Tax credits should be available.

Business health insurance is an example of a financial benefit you can offer your employees for their loyal service. One great benefit of business health insurance is providing a safer and more comfortable working environment for your workers.

It is expensive but beneficial, especially if you reach the out-of-pocket maximum where the insurer will pay the full coverage on the medical treatment needed by your employee. It will help you retain and attract potential new talent that you need for your business to flourish.

Select members you want to insure

• Grand Father
• Grand Mother
• Father-in-law
• Mother-in-law
• More Members

Get best pricing This will help us calculate the premium & discounts for your family

This will help us to find the network of Cashless Hospitals in your city

• Enter City Name or Pincode

Popular Cities

• Enter full name
• Enter mobile number

We will find you the plans that cover your condition.

Do any member(s) have any existing illnesses for which they take regular medication?

What is your existing illness?

Select all that apply

When did you recover from Covid-19?

Some plans are available only after a certain time

Health Insurance Premium Calculator

A health insurance premium calculator is an online tool that provides you with health insurance premiums for different plans. The calculator uses your age, family members to be insured, sum insured, policy tenure, and similar factors to derive the policy premium.

Health Insurance Premium Calculator Overview

Most people rely on their insurance companies to give them details on their premium payments. One would end up settling for one insurance policy just to avoid the research process. This is where the role of a mediclaim policy premium calculator comes into play. It is both timesaving and an effective tool.

Choose Health Insurance Coverage of Your Choice

For example, the health insurance premium paid by a person in their 20s will pay a lesser premium amount in comparison to someone who is in their 40s. As the person ages the possibility of catching illness also increases and therefore, the insurance companies charge a higher premium and also need them to undergo pre-medical screening before policy issuance.

Applicants with pre-existing ailments, tobacco users, and smokers are also at a higher risk and have more chances of filing a claim during the policy term in comparison to someone who is younger and does not have any pre-existing medical issues. 

PS - The starting price is indicative and may vary basis additional details.

What is Health Insurance Premium?

The Health Insurance Premium is the amount of money you need to pay periodically to an insurer in order to avail the medical coverage as well as to ensure that the policy remains in force. Health insurance premium calculator facilitates you to calculate your mediclaim premium, based on your insurance needs. In return, the insurer is liable to pay for the hospitalization expenses and medical bills in the event of a medical emergency or when an ailment is diagnosed subject to the policy terms.

Significant Benefits of Health Insurance Premium Calculator

Insurance policies are pretty complex and the policy documents generally have hidden terms and conditions. Sometimes, you don’t understand one or more insurance-specific terms and consequently, you have to pay way more than your expectations. What if you know in advance exactly how much premium you’ll have to pay for a  best health insurance policy ? Your life becomes so easy. The following are the benefits of health insurance premium calculator:

• Using health insurance premium calculator, you can have an estimate of the premium prior to purchasing the policy.
• You can efficiently choose a health insurance policy, based on a comparison between various similar plans.
• You can filter and shortlist the quotes as per your preferences
• Health insurance premium calculator also gives you an idea of the available discounts
• You get to know the cost of add-ons and optional benefits in advance
• Medical insurance premium calculator offers flexibility to change the data entered and the
• You can exclude or include add-on coverage through Riders provided by various insurance companies offering their plans online.
• You can make your decision when you actually want to proceed, as you don’t have to go and meet an insurance agent or a branch in person.

Health Insurers Premium Calculator

Aditya Birla Health Insurance Premium Calculator

Bajaj Allianz Health Insurance Premium Calculator

Bharti AXA Health Insurance Premium Calculator

Care (Religare) Health Insurance Premium Calculator

Cholamandalam Health Insurance Premium Calculator

Digit Health Insurance Premium Calculator

Future Generali Health Insurance Premium Calculator

HDFC ERGO Health Insurance Premium Calculator

ICICI Lombard Health Insurance Premium Calculator

Iffco Tokio Health Insurance Premium Calculator

Kotak Health Insurance Premium Calculator

Liberty Health Insurance Premium Calculator

ManipalCigna Health Insurance Premium Calculator

National Health Insurance Premium Calculator

New India Assurance Health Insurance Premium Calculator

Niva Bupa Health Insurance Premium Calculator

Oriental Health Insurance Premium Calculator

Raheja QBE Health Insurance Premium Calculator & Premium Chart Online

Reliance Health Insurance Premium Calculator

Royal Sundaram Health Insurance Premium Calculator

SBI Health Insurance Premium Calculator

Star Health Insurance Premium Calculator

TATA AIG Health Insurance Premium Calculator

United India Health Insurance Premium Calculator

Universal Sompo Health Insurance Premium Calculator

Zuno Health Insurance Premium Calculator

How is Health Insurance Premium Determined?

• Medical History

Pre-medical screening or medical history is required to determine the health insurance premium based on the results. In some plans medical exam may not be required but your current health conditions, family health background, and lifestyle-related habits are taken into consideration. The premium for smokers is usually on a higher side.

Entry Age and Gender

Age is an important determining factor while calculating health insurance premium. The premium increases with the age of the proposer. At a higher age, people are more prone to critical illnesses, such as cardiovascular diseases, kidney disorders and the likewise. This is the reason why premium for a senior citizen health insurance plan is usually higher than a basic health plan. Also, the premiums for female candidates are lower as compared to the male candidates due to lower risk of heart attack, stroke, etc.

Policy Term

The premium for a one-year health insurance plan will be lower than a 2-year plan. However, the insurer provides a discount if you buy a long-term policy.

It’s a well-known fact that the plan selected by you is going to affect the premium cost. The lower the risks involved the lower the premium will be and vice-versa. A wisely chosen and weighed plan on a health insurance premium calculator will help you get numerous benefits and desired premium for you.

No-Claim-Bonus

It is the discount that you get on your insurance premium for all the years that you haven’t claimed. It is an important factor to be considered before calculating the health insurance premium.

If you are a smoker or drink regularly, the chances are that you will be paying an extra amount of premium. In fact, the company can deny issuing your policy.

Additional Factors Affecting Health Insurance Premium

Insurance companies have certain guidelines related to mediclaim and they do follow them all each time they issue an insurance policy to an individual; same goes for a health insurance policy. Below is a list of such guidelines that are followed by most insurers:

The expenses related to marketing and services are quite large in number, which are certainly recovered from the premiums paid by the policyholders. These expenses in details are drafted as the designing cost of a medical insurance policy followed by the marketing, commission, brokerage, brochure, advertisement, and all other additional costs. The list also includes the operational cost incurred by the insurance companies.

Insurance companies invest their capital in public sector investment instrument. These companies typically avoid investing in the private sector due to excessive risk. Each of these investments made follows the guidelines of the IRDA of India to avoid any compliance issue later. The premium you need to pay for a health insurance policy is subject to the returns gained from such capitalizations.

Insurance companies have various types of a single health insurance policy, such as individual health insurance, family floater health insurance, and  group health insurance . These companies get their mediclaim policies underwritten in such a manner that there is a balance between all of them at the same time. They also analyze the possible risks from one or more angles and take into account a wide range of factors that could cause troubles. Based on that, different mediclaim policies get their specific criteria of eligibility and instances, such as when to deny the coverage to a policyholder. Apparently, these steps are taken in order to avoid losses in the future.

There are times when the insurance companies have liabilities and they have to pay the sum assured to the insured person or their family members in a case of emergency hospitalization. The mortality rate is nothing but the cost an insurance company has to bear in a case of an eventuality to a customer. While these expenses vary with the age group, such liabilities arise often in the case of older customers. This is because:

• Insurance premium for old age customers is comparatively high
• Old age customers are more prone to diseases and subsequent hospitalization due to high blood pressure, diabetes, heart attack etc.
• Sum assured is higher for old age customers; so is the premium then.

Although all insurance general companies require you to undergo a complete health check-up before issuing you a health insurance policy, some just leave it on you and proceed with the information you provide to them in the application form. Insurance companies need to document your present health condition, family health background, smoking/drinking habit before issuing you a health insurance policy. Based on this information, the premium payable for the coverage is calculated, which you have to pay to avail the policy benefits. This also means that those who have a medical history or a condition at present will have to pay an additional premium to avail the coverage.

How to Reduce Health Insurance Premium?

As more and more people realize the importance of having a health insurance cover , the cost of premium still remains a concern with many. Though mediclaim policies with a lower premium might not offer adequate health cover, but here are some ways of reducing your health insurance premium:

• Opt for Higher Deductibles- It is the percentage of amount that the insured needs to pay on his own for the treatment. In some health plans the deductibles are compulsory and in some they are voluntary, where in you have option to opt for it. Opting for a higher deductible will reduce the health insurance premium. But it is only recommended for those who can bear the certain cost of treatment on their own. 
• Select Family Floater Plans- Family floater plans cover 2 or more members under the same policy. It is suitable for those who want to cover their spouse and children under the same plan and the premium is not paid separately for each member. It reduces the premium significantly. The only catch is that the sum insured amount is available only on floater basis and not on an individual basis. 
• Opt for a Multi-year Mediclaim Policy-  The premium for annual health plans is higher in comparison to multi-year plans bought for 2 or 3 years. The premium is paid at once and most of the insurers offer discount on mediclaim policies bought for a tenure of more than 1 year.
• Compare Medical Insurance Quotes- The health insurance premium varies from one insurance company to another. And the premium for different mediclaim policies also varies. Comparing different health insurance quotations would help you decide and purchase an adequate medical policy to meet your healthcare requirements
• Opt for Top-up Health Plans- To enhance the coverage benefits you can buy a top-up health plan alongside your existing mediclaim policy. The premium for top-up plans is less, and is useful when your base sum insured gets exhausted.

Aditya Birla Health Insurance

Bajaj Allianz Health Insurance

Bharti AXA Health Insurance

Care Health Insurance

Cholamandalam Health Insurance

Digit Health Insurance

Future Generali Health Insurance

HDFC ERGO Health Insurance

IFFCO Tokio Health Insurance

Kotak Mahindra Health Insurance

Liberty Health Insurance

Magma HDI Health Insurance

ManipalCigna Health Insurance

National Health Insurance

New India Health Insurance

Niva Bupa Health Insurance

Oriental Health Insurance

Raheja QBE Health Insurance

Reliance Health Insurance

Royal Sundaram Health Insurance

SBI Health Insurance

Star Health Insurance

Tata AIG Health Insurance

United India Health Insurance

Universal Sompo Health Insurance

ZUNO Health Insurance

Tax Benefit of Health Insurance

In addition to the medical coverage, health insurance policies also have a tax benefit under section 80D of the Income Tax Act, 1961. In other words, the premiums you pay for a health insurance policy entitles you to avail tax exemption under the IT section 80D, where the maximum tax exemption you can avail in a financial year is Rs. 25,000 if you’re below 60 years of age. On the flip side, if you’re a senior citizen, then this limit goes to Rs. 30,000 in a financial year.

Simply put, the more you pay as health insurance premium, the more you save on your income tax. Use health insurance premium calculator to figure out how much you have to pay to avail sufficient health coverage.

In case you are the breadwinner (sole earner) in your family and are paying the health insurance premiums for your family (spouse and children) as well as for your parents, then you can avail a combined tax exemption of Rs. 55,000 in a financial year.

You can also avail an additional tax exemption of Rs. 5,000 subject to the annual health checkups.

Note: In order to avail the tax exemption, you must pay your health insurance premiums via a Cheque or Internet Banking. In case you paid your health insurance renewal premium via cash last year, you would not be able to claim tax exemption, based on that payment.

How to Use Health Insurance Premium Calculator by Policybazaar?

Policybazaar provides you with an advanced health insurance premium calculator that does exactly the same function for you. This online premium calculator facilitates you to calculate the premiums of various health insurance policies and provides you with a free quote. You can compare various health insurance policies based on not only the premium but also the benefits under the coverage umbrella.

With this mediclaim policy premium calculator, all you need to do is provide your personal details along with the details of your family for which you want to purchase the policy. Based on the information provided, this premium calculator compares a range of health insurance policies that are ideal for you. Choose the best plan for you in your budget, based on the coverage and not just the premium.

Explore Other Health Insurance Plans

How to use health insurance premium calculator.

To use a health insurance premium calculator online, follow the steps given below:

• Visit Policybazaar Insurance Broker Private Limited’s official website
• Go to the ‘Insurance Products’ menu at the top of the page
• Select ‘Health Insurance Calculator’ under the ‘Health Insurance’ category
• On the landing page, scroll down to the ‘Health Insurance Premium Calculator’ widget
• Select the city in which you stay
• Choose the people for whom you want to buy a health policy
• Enter the age of the eldest member to be insured and click on ‘Continue’
• Select the cover amount you want under your policy and click on ‘Calculate’
• The premium for various health insurance plans as per your preference will be displayed.
• Click on ‘View All Plans’ to check the premiums of all available plans.

You can also compare multiple plans online to find the best health insurance plan within your budget. You can also get in touch with the Policybazaar customer support team in case of any query.

Now, you can see various health insurance policies with their features and corresponding premiums. Choose two or more health insurance policies to compare and pick out the best one using the mediclaim premium calculator. You can also chat with the Policybazaar support team for any query you may have.

Q: What is a health insurance premium calculator?

Q: is calculating your health insurance premium possible online, q: why should i use an online premium calculator, q: what kind of information do i have to provide while using health insurance premium calculator, q: does the calculator ask for health related habits, q: what are the payment options provided by the health insurance premium calculator, q: how much time do i have to invest online in order to calculate insurance premium, q: why should i use health insurance premium calculator.

• 30 minutes claim support ## (In 120+ cities)
• Relationship manager For every customer
• 24*7 claims assistance In 30 mins. guaranteed*
• Instant policy issuance No medical tests ~

Aditya Birla

Bajaj Allianz

Cholamandalam

Future Generali

IFFCO Tokio

Kotak Mahindra

ManipalCigna

Royal Sundaram

United India

Universal Sompo

Health insurance articles

• Recent Article
• Popular Articles

Everything about the Activ One Plan by Aditya Birla Health...

In a time when increasing healthcare costs can create a

10 Reasons Why Your Health Insurance Claim Can Get Rejected

Health insurance plans add a layer of invisible protection against

Knee Replacement Surgery Cost in India

Knee pain has become a very common ailment in India, with over 15

Kidney Transplant Cost in India

Kidney disease has been growing at an alarming rate in India. As

How Can NRIs Save Taxes on Health Insurance in India?

Health insurance is an essential buy for people in India as well

How to Apply for Ayushman Bharat Pradhan Mantri Jan Arogya...

Ayushman Bharat Yojana is a flagship health insurance scheme launched by the Government of India to offer universal

Best Health Insurance Plans for Senior Citizens in 2023

Senior citizens are the most prone to diseases. Considering the medical inflation in India, buying health insurance

10 Major Benefits of Ayushman Bharat Yojana

Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the second component under Ayushman Bharat Scheme. PM Narendra Modi

Does Health Insurance Provide Coverage for LASIK Eye...

A vast majority of the Indian population is suffering from vision problems. For some of them, LASIK eye surgery is

Pre-Existing Disease (PED) Cover from Day One

Pre-existing diseases (PED) are mostly expensive to treat as they are chronic in nature. Unfortunately, most health

*We will respond in the first instance within 30 minutes of the customers contacting us. 30-minute claim support service is for the purpose of giving reasonable assistance to the policyholder in pursuance of the claim. Settlement of claim (including cashless claim) is the responsibility of the insurer as per policy terms and conditions. The 30-minute claim support is subject to our operations not being impacted by a system failure or force majeure event or for reasons beyond our control. For further details, 24x7 Claims Support Helpline can be reached out at 1800-258-5881. Product information is authentic and solely based on the information received from the Insurer. Policybazaar is acting only as a facilitator and claims settlement shall be at the sole discretion of the Insurer. As per the Insurance guidelines, you are allowed to cancel the policy with-in 15 days from the date of Issuance of policy. For more details, please read the Plan Brochure carefully or talk to our advisor at the time of purchase.

**All savings and online discounts are provided by insurers as per IRDAI approved insurance plans. #Tax Benefits are subject to changes in tax laws.

##On ground claim assistance is available in 114 cities

~No medical tests are required unless requested by the insurer’s underwriter. In-case of pre-existing diseases relevant medical proof would be required as per the terms and condition of the policy opted.

^Source - Google Review Rating available on:- http://bit.ly/3J20bXZ

• Car Insurance
• Bike Insurance
• Motor Insurance
• Third Party Car Insurance
• Third Party Bike Insurance
• Travel Insurance
• Commercial Vehicle Insurance
• Life Insurance
• Term Insurance Calculator
• 1 Crore Term Insurance
• Term Return of Premium
• Term Insurance for Housewife
• Spouse Term Plan
• Term Insurance
• Term Insurance For NRI
• Best Term Insurance Plan
• Term Insurance for Women
• No Cost Term Insurance
• Term Insurance Glossary
• Investment Plans for NRIs
• Pension Plans for NRIs
• Guaranteed Return Plans for NRIs
• Child Plans for NRIs
• Investment Plans with High Returns
• Money Back Policy
• Endowment Policy
• Tax Saving Plans
• Saving Plan
• Investment Funds
• Income Tax Calculator
• SIP Calculator
• NPS calculator
• FD Calculator
• Health Insurance
• 1 Cr Health Cover
• Family Health Insurance
• Senior Citizen Health Insurance
• Coronavirus Insurance
• Corona Kavach Policy
• Corona Rakshak Policy
• Arogya Sanjeevani Policy
• Group Health Insurance
• Cyber Insurance
• D&O Insurance
• Workers Compensation
• Business Insurance
• Cancer Insurance
• Home Insurance
• Customer reviews
• Insurance companies
• Legal & Admin policies
• Verify your advisor

Payment Methods

Secured With

Follow us on

Policybazaar Insurance Brokers Private Limited CIN: U74999HR2014PTC053454 Registered Office - Plot No.119, Sector - 44, Gurgaon - 122001, Haryana Tel no. : 0124-4218302 Email ID: [email protected]

Policybazaar is registered as a Direct Broker | Registration No. 742, Registration Code No. IRDA/ DB 797/ 19, Valid till 09/06/2024, License category- Direct Broker (Life & General)

Visitors are hereby informed that their information submitted on the website may be shared with insurers.Product information is authentic and solely based on the information received from the insurers.

© Copyright 2008-2023 policybazaar.com. All Rights Reserved.

Best health plan for you and your family.

*All savings provided by insurers as per IRDAI approved insurance plan. Standard T&C apply.

Health Insurance Plan Comparison Calculator

What Will It Really Cost You?

A Free Calculator to Compare Health Insurance Plans from your Marketplace or Employer

Hi and welcome. A couple of items before you get started:

1. You can’t use decimals here, except in the percentage fields. They won’t “take.” Round to dollars.

2. If you let this sit for a while, the server will clear your entries. So if you have to walk away, you should grab a screen shot first, print, or download the data so you can pull it into a spreadsheet.

What’s your exposure? With so many variables, comparing health insurance plans can be really hard. What will they pay and what will they cost when you actually use them?

This calculator’s especially good at helping you rule out the bad deals and focus on the better ones. Enter premiums (after subsidies) and other values for the plans you’re considering, then roll over the lines in the graph to see your total outlays.

An example of how to use this:  Why would anyone buy the purple plan here for an extra thousand dollars a year, instead of the green plan, which offers the same or better financial protection? Turn off the blue and orange checkboxes to see that comparison clearly, and zoom the X axis to get a close-up look at how more-typical healthy years will play out.

A note on zero-percent coinsurance. If you enter zero for the coinsurance percentage (the share you pay after you’ve spent the deductible limit, until you hit the out-of-pocket limit), the graph will show you never paying more than the deductible — never getting to the OOP. But some things in your plan probably  aren’t 0% coinsurance. You will pay more, even after your deductible. So: If your plan has 0% coinsurance, still, enter some percentage — 10% or whatever — in this field to see your actual annual out-of-pocket exposure on the graph.

Things to Consider When Using This App

Copays and coinsurance.  Best bet is to enter the plan’s coinsurance percentage for hospitalization, since that is your greatest financial exposure.

Many plans have fixed (generally low) co-pay amounts instead of percentage “co-insurance” for many services, even before you reach your deductible. There’s no way to display that without you entering how many visits, lab tests, etc. you might have. (Gets way too complicated.) Enter your plan’s percent coinsurance, and figure your outlays will be somewhat lower than what you see above because of the low fixed copays for office visits etc.

Extra deductibles and copays. Your total outlays shown above do not include additional amounts you might spend due to some plans’ extra copays and deductibles for emergency/urgent care, doctor visits, drugs, etc.

Most plans don’t have these extras, they vary a lot between plans, and are usually small when they do exist. But sometimes they’re quite significant. If a plan has high exceptions like this, they could significantly increase your spending beyond what you see above (the relative significance would be higher in “normal,” relatively healthy years shown in the lower-left of the graph). In most cases these extra charges count towards your annual out-of-pocket limit, so they don’t affect the “worst case” (upper-right) outlay scenario. But check each plan carefully for these kind of “gotchas.”

Out-of-network spending.  If you expect to get all your care from in-network providers (“preferred” providers who are contracted with your insurer), you can skip entering out-of-network information, and ignore the out-of-network lines on the graph.

Out-of-network spending is mostly significant in worst-case situations — some special injury or illness for which you need a specialized clinic or doctor that is not in your insurer’s network. (i.e. You need to fly to the Mayo Clinic or some such for a special cancer treatment.)

Traditionally, out-of-network charges have been more of an issue for rural dwellers who might need to travel to get care, but insurers are paring their networks severely these days, even in urban centers.

Some plans have no out-of-pocket limit on out-of-network payments: In some you’re responsible for unlimited percentage copays, while in others (Exclusive Provider Organizations or EPOs, and many perhaps most HMOs) there’s no out-of-network coverage at all; you pay for everything. These plans will usually save you money on premiums; you have to decide whether that savings is worth the (perhaps unlikely) risk of needing an out-of-network provider. The risks: 1. You’ll have to pay for the provider; 2. You’ll have to decide whether to pay for the provider.

National and multi-state provider networks.  Some insurance plans are contracted with large national networks of providers, so you can pay in-network even for providers in other cities and regions. (Most plans do cover out-of-state emergencies.) Others offer in-network coverage in two states at once for people who have two residences. This may be important, for instance, for families in which one member is out of state — a child at college, for instance.

Family vs. Individual.  Most family plans have individual and family deductibles and out-of-pocket limits. (Family is often twice the individual amount.) This can make it hard to evaluate your exposure and compare plans. To best judge your worst-case financial exposure — what happens if two of you get really sick — enter the family deductible and OOP amounts in the calculator rather than the individual amounts. This worst-case two-illness scenario is less likely to occur, of course, but the financial hit can be serious if it does.

Drug Costs. Some plans just include drug spending in the normal deductible, copay, and out-of-pocket totals. But different plans’ drug provisions vary wildly. As with normal coverage, watch out for big upside gotchas that could result in a bad financial hit if you need expensive drugs for a long period. Some plans only cover generic drugs (which tend to be cheap in any case so why not just pay for them yourself?), but don’t cover more expensive (often wildly more expensive) brand-name drugs that you may need.

Uncovered spending. Some things just aren’t covered. Read your plan’s Benefit Summary carefully to judge your exposure if you think you might feel the need for those services.

Read the limitations and exclusions . These are usually  not included on the Summary of Benefits; you have to ask for them specifically. For instance, some plans don’t cover injuries incurred when you’re intoxicated or high — or your child is. (This exclusion is illegal in many states.) This could result in some very nasty financial surprises, if they decide to enforce these provisions when a big bill comes in.

Bottom Line.  Insurers don’t sell you insurance because they’re losing money on it. As in casinos (you are placing a bet here), the house always takes a cut. Rolling over the left side of the graph, you’ll see that in healthy years you spend more than you would if you just paid for health care yourself . (Though you wouldn’t have the insurer’s bargaining power/network price markdowns working for you.) That’s the cost of protecting yourself against worst-case years.

So if you buy “cadillac” plans that pay for everything (and pay the high premiums that go with those plans), your insurer takes a cut on everything. Over the course of your life, the odds are you’ll spend more in total premiums plus out-of-pocket costs.

The lesson: buy the lowest-premium insurance you can find that protects you from spending levels that could significantly damage your savings, your life, and your lifestyle. You have to decide whether the savings on premiums during healthy years (and the additional personal savings you can  but might not sock away as a result) make a low-cost plan sensible and worthwhile.

Ah but there are always more exceptions, aren’t there? Here are two:

• There’s another advantage to more-expensive pay-everything plans: you know more accurately how much you’ll spend each year. You pay extra for that certainty. That may be worth it to you.

• Under the ACA provisions, insurers can’t charge you more in premiums because you have a pre-existing condition. If you know that you’ll have significant health expenses in coming years, a higher-premium pay-everything plan may result in lower total outlays for you. If you buy a cheap plan with high deductible and OOP limits, you might get hit hard in one year, but if those charges are going to continue, you’ll be able to shift to a pay-everything plan in ensuing years. The graph above can help you judge those tradeoffs.

Hot tip:  If you’re shopping for an individual plan and your income’s low enough that you’re eligible for a subsidy,  check out the silver plans . There’s an additional, hidden “Cost Savings Reduction” subsidy for those plans. It doesn’t show as a reduced premium; rather, you pay the same premium as higher-income people do, but get a lower deductible and/or out-of-pocket limit based on your income level. It’s a deal. There’s significant savings to be had here.

Finally: Best wishes for a healthy and prosperous life for you and your family!

To download the data behind the graph: 

When you enter values, the app builds a data table and graphs it. If you’d like to mess with the data in a spreadsheet or some such, or just save it for later, here’s how:

1. Click the Data Table tab at the top.

2. Click the arrow icon at the bottom of the data table and choose Data from the popup menu.

3. Click “Download all rows as a text file.”

About me and this page: 

This page was created by me, Steve Roth. I built a spreadsheet to do this analysis for myself years ago, and then hired a very talented fellow to build it out into this web app. Full disclosure: if this page attracts a decent amount of traffic, I’m hoping to post some ads and make some money. But to that end, I’ve just tried to provide the most useful app and information I can.

The information and analysis on this site is provided free to anyone on the internet who stumbles across it. You should evaluate it with the same care that you would any internet (or other) information. While great effort has been expended to make the information and arithmetic here accurate and useful, there is no warranty or guarantee, implicit or explicit. This page and this app are not the work of an insurance or health-care professional. It’s not professional advice, and you are solely responsible for reviewing and using it with care and judgment.

Comments and questions are welcome! Write me at: info at health-plan-compare dot com.

One thought on “What Will It Really Cost You?”

• Pingback: I use my health insurance plan to save for retirement instead of paying medical bills, and it's one of the smartest financial choices I've made | Money Training Club

Comments are closed.

• How to evaluate the cost of employee health plans

Once you’ve decided to offer employee health benefits, it’s time to choose the best plan for you, your company and your employees.

Selection often starts with cost. The cost of group health insurance is comprised of several moving parts that work together to contribute to the bottom line. To evaluate the cost (especially when you’re comparing plans) consider the premium—the amount paid to the insurance company each month for coverage—against other costs, such as co-payments, deductibles and coinsurance.

Here’s some guidance to help you weigh the numbers:

Understand how the pieces fit together.

A higher premium will generally mean a lower deductible, or the amount an employee must pay toward medical costs before the insurance plan kicks in. Conversely, smaller premiums will usually lead to a higher deductible, which means employees will pay more if they need medical care. The two variables work a bit like car insurance; if you raise your accident deductible to $2,000, your monthly payments will go down—but if you're in a crash, you'll owe $2,000 before your insurance pays for any damage.

Don’t forget out-of-pocket costs.

The right health plan for your small business is the one you can afford, and employees can afford to use. Copayments and coinsurance, the payments that go along with medical visits, can add up if employees see a doctor frequently, and co-payments often don't count toward a deductible.

• A copay is a fixed dollar amount paid by employees when they use medical services. For example, a doctor visit may have $35 copay, whereas an ER visit may be $200.
• Coinsurance is the percentage of cost an employee pays for medical services, after she’s met her deductible. Consider a $100 doctor visit with a 20% coinsurance. If the employee has met her deductible, she would pay $20 and the insurance company would pay the remaining $80.

Find out what’s important to your employees.

Employees may care more about catastrophic coverage than regular checkups with a low co-payment. Understand employees' financial preferences, too. People with chronic health conditions or with small children—who tend to require frequent trips to the doctor—may lean toward higher premiums with lower co-pays, while a young, healthy workforce may favor a smaller up-front cost.

Also take a look at the plan's network – this determines which doctors you and your employees can see. When you're comparing plans that share the same base price, take a closer look at the network to make sure the doctors and hospitals employees desire most are in the plan’s network.

A well-placed survey ,PDF opens new window or quick poll can help you determine how the bulk of your employees feel.

And regardless of which plan you’re considering, talk to your accountant. An employer’s contributions to healthcare costs are typically tax deductible. Your accountant can explain how deductions help offset the cost, potentially making benefits more affordable than you may think.

About Group Health Benefits

Humana answers your questions.

Products and Services

We’ll help you get the most from your employee benefits

Products and services

Learn about employee health benefits

Get details about wellness solutions

Get started with employee benefits

Help and support.

Find tools, answers to frequently asked questions and contact information.

Article library

Get ideas on how your organization can continue to evolve and grow.

Webinars and other resources

View insights and trends in healthcare and workplace organization.