Health plan total-cost worksheet

Purpose, who it is for and how to use it

Purpose: put two plans on the same footing by adding up a likely year and a bad year for each.

Who it is for: anyone choosing between two plans, whether bought through HealthCare.gov, Covered California or another state marketplace, offered by a job, or one of each. Medicare plans follow different rules; Medicare open enrollment for 2027 covers those choices.

How to use it:

1. For each plan, get the Summary of Benefits and Coverage (SBC), your premium after any tax credit or employer share, and the plan's drug list.
2. Fill in Part A for each plan.
3. List the care you expect next year in Part B.
4. Work through Part C once for each plan.
5. Before you decide, check networks and medicines with Part D. How to compare two health plans beyond the premium explains each step.

Write in pencil. Do not write member ID numbers, Social Security numbers or diagnoses on this page.

Part A: Plan facts (from each plan's SBC)

Part B: Care you expect next year

For each service, write how each plan charges for it:

• P — preventive care at no cost in network (enter $0)
• C — a copay that applies right away (enter copay × times per year)
• D — goes through the deductible, then coinsurance (enter the full price × times per year)

"Full price" here means the plan's allowed amount: the price the plan has agreed to pay, not the provider's list price.

Total of C amounts → line 2. Total of D amounts → line 3.

Part C: The worksheet

The formula

• Line 1 = premium per pay period × pay periods per year (for a monthly premium, 12 × monthly premium)
• Line 4 = min(line 3, deductible)
• Line 5 = max(0, line 3 − deductible) × coinsurance
• Line 6 = line 2 + line 4 + line 5
• Line 7 = min(line 6, out-of-pocket maximum)
• Line 10 = line 1 + line 7 + line 8 − line 9
• Line 11 = line 1 + out-of-pocket maximum + line 8 − line 9

In short: yearly cost = 12 × monthly premium + expected cost sharing, with cost sharing for covered, in-network care capped at the out-of-pocket maximum.

Units: U.S. dollars for one plan year. Coinsurance is a decimal (20 percent = 0.20). "Times per year" is a count.

Assumptions:

• Everything in Part B is covered and in network, unless you moved it to line 8.
• The deductible, copays and coinsurance for covered, in-network care count toward the out-of-pocket maximum. Premiums do not.
• Preventive care from an in-network provider costs $0. Some visits that start as preventive can still produce a charge.
• Nothing has been paid yet toward this plan year's deductible or out-of-pocket maximum.
• This sheet does not count copays toward the deductible. If your plan does, your real cost may be a little lower.

Rounding: use whole dollars. Work out line 5 in full, then round to the nearest dollar. Round nothing else until lines 10 and 11.

Missing values:

• You do not know a price. Ask the provider's billing office for the plan's price, use the plan's cost estimator if you have access, or look at the sample costs in the SBC. Write "estimate" beside the line.
• You do not know how much care you will need. Do the sheet three times, for light, medium and heavy use.
• A service shows a copay "after deductible." Put its full price on line 3 for the visits you expect before the deductible is met, and its copay on line 2 for the visits after.
• You cannot find the out-of-pocket maximum. Ask the plan. You need it for lines 7 and 11.
• No employer deposit. Enter 0 on line 9.

Edge cases:

• Family plans. Do Part B and lines 2 to 6 for each person. Cap each person at the plan's individual out-of-pocket maximum, or, if the plan lists only a family limit, at the federal limit for one person ($12,000 for 2027 plans). Then cap the family total at the family maximum. If each person has an individual deductible inside the family deductible, use it for each person and stop when deductible payments reach the family amount. If the family must meet one deductible together, as in some HSA-compatible plans, apply the family deductible to the family's combined line 3.
• A separate deductible for medicines. Run lines 3 to 5 for medicines on their own, using that deductible, and add the result to line 6.
• Expected costs above the cap. Line 7 equals the out-of-pocket maximum, and your likely year and bad year are the same.
• Out-of-network care. It goes on line 8 and is not capped, and the provider may bill above the plan's allowed amount. Emergency care and some care at in-network hospitals have federal protections; How to read an itemized hospital bill before you dispute it explains them.
• Starting or switching mid-year. What you paid under an earlier plan may not count toward a new plan's deductible or maximum. Marketplace plans run on the calendar year; a job-based plan year can start in any month.
• Paycheck premiums. Multiply the per-paycheck amount by 26 or 24, not by 12.
• Tax credits. If your income changes, your premium after help changes too. Starting with tax year 2026, extra advance credit you received must be repaid in full at tax time.
• Cost-sharing reductions. If you qualify, use the lower Silver plan amounts shown in your marketplace eligibility results.
• Tax savings are not counted. HSA, FSA and pre-tax payroll savings are left out. HSA or FSA? How each works explains those.

Worked examples (fictional)

The plans and prices below are made up to show the arithmetic. They are not real plans.

Example (fictional) 1: a single adult who uses little care. She pays monthly and compares a Bronze plan with a Silver plan. She expects one checkup, two sick visits ($160 each), one lab test ($60) and one generic medicine each month.

• Plan A (Bronze): $180 a month; $6,500 deductible; 40 percent coinsurance; $9,800 out-of-pocket maximum. Visits and labs go through the deductible; generic medicine is a $20 copay.
• Plan B (Silver): $290 a month; $4,700 deductible; 30 percent coinsurance; $9,200 maximum. Sick visits are a $50 copay; labs go through the deductible; generic medicine is a $20 copay.

Plan A costs $1,100 less in a likely year and $720 less in a bad year.

Example (fictional) 2: a long-term condition and a planned procedure. He compares a Bronze plan with a Gold plan. He expects six specialist visits ($250 each), a brand-name medicine every month ($450 a fill), four lab tests ($80 each) and an outpatient procedure ($4,000).

• Plan A (Bronze): $180 a month; $6,500 deductible; 40 percent coinsurance; $9,800 maximum. All of this care goes through the deductible.
• Plan B (Gold): $400 a month; no deductible; $70 specialist copay; $75 copay for the medicine; $35 lab copay; 20 percent coinsurance for the procedure; $7,800 maximum.

Plan B costs $3,488 less in his likely year, even though its bad year is $640 higher. When you expect a lot of care, the likely year matters more than the lowest premium.

Example (fictional) 3: a family choosing between two job-based plans. A family of four is paid every two weeks (26 paychecks). Parent 1 has a planned knee surgery ($18,000) and two specialist visits ($200 each). Parent 2 has a checkup and a generic medicine every month ($25 a fill). The two children have checkups and three sick visits between them ($140 each).

• Plan A (PPO): $260 a paycheck; deductible $1,000 a person, $2,000 a family; 20 percent coinsurance; maximum $4,000 a person, $8,000 a family. Copays apply right away: $30 primary care, $60 specialist, $15 generic.
• Plan B (HSA-compatible): $150 a paycheck; one $4,000 family deductible that applies to all care except preventive; 20 percent coinsurance; maximum $7,000 a person, $14,000 a family; employer HSA deposit of $1,500.

Plan A, person by person:

• Parent 1: copays $60 × 2 = $120; surgery $18,000, so deductible part $1,000 and coinsurance part $17,000 × 0.20 = $3,400; total $4,520, capped at $4,000 (the per-person maximum).
• Parent 2: $15 × 12 = $180.
• Children: $30 × 3 = $90.
• Line 7 for the family: $4,000 + $180 + $90 = $4,270, under the $8,000 family maximum.
• Line 1: $260 × 26 = $6,760. Line 10: $6,760 + $4,270 = $11,030. Line 11: $6,760 + $8,000 = $14,760.

Plan B, as a family:

• Line 3: $18,000 + $400 + $300 + $420 = $19,120.
• Line 4: $4,000. Line 5: ($19,120 − $4,000) × 0.20 = $3,024. Line 6: $7,024. Parent 1's share can be no more than $4,000 + ($18,400 − $4,000) × 0.20 = $6,880, under the $7,000 per-person maximum, so line 7 is $7,024.
• Line 1: $150 × 26 = $3,900. Line 9: $1,500. Line 10: $3,900 + $7,024 − $1,500 = $9,424. Line 11: $3,900 + $14,000 − $1,500 = $16,400.

Plan B costs $1,606 less in the likely year. Plan A costs $1,640 less in a bad year. With Plan B, the family also needs several thousand dollars on hand when the surgery bill arrives, so the timing of large costs matters as well as the totals.

Example (fictional) 4: lower income, with cost-sharing reductions. A single adult's income qualifies him for cost-sharing reductions. He compares a $0-premium Bronze plan with a Silver plan that includes those savings. He expects three sick visits ($150 each), a generic medicine every month and, to be safe, one emergency room visit ($2,000).

• Plan A (Bronze): $0 a month; $6,500 deductible; 40 percent coinsurance; $9,800 maximum. Visits and emergency care go through the deductible; generic medicine is a $20 copay.
• Plan B (Silver with cost-sharing reductions): $25 a month; no deductible; $10 visits; $5 generic medicine; $50 emergency room copay; $1,400 maximum.

The Silver plan costs $2,250 less in the likely year and $8,100 less in a bad year, even though its premium is higher.

Part D: Before you decide

• Every doctor, hospital and pharmacy I need is in each plan's network, confirmed by phone, with the date written down.
• Every medicine is on each plan's drug list. I noted its tier and any prior authorization, step therapy or quantity limit.
• I know which care needs a referral or approval under each plan.
• I could pay each plan's bad-year total, or I have a plan for how I would.

Limitations

• This is an estimate, not a quote. Actual costs depend on the care you get, the prices your plan has agreed to and your plan's exact rules.
• The model is simplified. Some plans have several deductibles, copays that change after the deductible, or limits on visits. Your plan's Evidence of Coverage or policy has the full rules.
• It does not decide whether you qualify for a tax credit, cost-sharing reductions or an HSA. Your marketplace or employer decides that.
• It is not tax or legal advice.

Sources

1. Your total costs for health care: premium, deductible and out-of-pocket costs — HealthCare.gov, Centers for Medicare & Medicaid Services, accessed October 21, 2026.
2. Out-of-pocket maximum/limit (glossary) — HealthCare.gov, accessed October 21, 2026.
3. Preventive health services — HealthCare.gov, accessed October 21, 2026.
4. Premium adjustment percentage, maximum annual limitation on cost sharing, and required contribution percentage for the 2027 benefit year — Centers for Medicare & Medicaid Services, January 29, 2026.
5. Revenue Procedure 2026-24 (2027 HSA and high-deductible health plan amounts) — Internal Revenue Service, accessed October 21, 2026.
6. FAQs about Affordable Care Act Implementation (Part XXVII) — U.S. Department of Labor, accessed October 21, 2026.
7. Embedded self-only annual limitation on cost sharing FAQs — U.S. Department of Health and Human Services, accessed October 21, 2026.
8. 2027 Patient-Centered Benefit Plan Designs (final approved) — Covered California, June 18, 2026.
9. 45 CFR 147.200, Summary of benefits and coverage and uniform glossary — Electronic Code of Federal Regulations, accessed October 21, 2026.
10. IRS updates frequently asked questions on the Premium Tax Credit (IR-2025-127) — Internal Revenue Service, December 23, 2025.
11. 45 CFR 155.305, Eligibility standards (cost-sharing reductions) — Electronic Code of Federal Regulations, accessed October 21, 2026.
12. Health plan categories: Bronze, Silver, Gold and Platinum — HealthCare.gov, accessed October 21, 2026.