Patient Cost Estimator

The rule this applies. Cost sharing comes out of the allowed amount, never on top of it: the federal uniform glossary defines the allowed amount as “the maximum payment the plan will pay for a covered health care service,” and defines coinsurance as a percentage of that amount, after which “the plan pays the rest of the allowed amount.” So the patient’s share and the plan’s payment always add up to exactly the allowed amount. A copay is cost sharing too, so it is part of that total rather than an extra charge beside it.

What this tool assumes, because no rule fixes it. It takes the copay off the top, applies the remaining deductible next, and charges coinsurance on whatever is left. The glossary settles the two ends of that — before the deductible is met the patient owes the whole allowed amount, after it they owe the coinsurance percentage — but not where a copay sits in the order, and plan designs genuinely differ (many apply a copay instead of coinsurance for a given service type). It also takes no out-of-pocket maximum, so once a patient reaches theirs the plan pays 100% and the real figure is lower than this one. Read the result as an upper bound, and let the payer’s adjudication govern the real balance.

Use the eligibility response for the deductible and cost-share figures, and see estimating patient cost-share before service for the full workflow.