Standard Tier Module
Patient Cost-Share Estimator (deductible / coinsurance / copay / OOP)
Estimate what the patient owes and what the plan pays - exact, auditable, entirely in the browser.
See it run - a worked example, 100% in this browser tab
The problem
Front-office and billing teams quote patient responsibility from plan parameters by hand, and a missed step in the deductible-then-coinsurance order or the out-of-pocket cap produces estimates that do not match the payer's remittance.
The local-first solution
This plugin runs the standard cost-share adjudication order as exact, step-by-step arithmetic in your browser, returning patient and plan responsibility with a reconciled breakdown - deterministic, citation-backed, and with no PHI transmitted to any cloud.
What it does
Applies the contracted allowed amount and separates the contractual write-off the patient does not owe
Charges the deductible first, then coinsurance or a flat copay on the remainder
Caps total patient cost at the remaining out-of-pocket maximum and zeroes the patient past it
Flags out-of-network balance-billing and No Surprises Act considerations
Tracks remaining-deductible and remaining-OOP after the service
Returns a step-by-step breakdown plus patient, plan, and write-off totals
Honest scope
This is an estimate from the plan parameters you enter; the payer's actual adjudication (the EOB / remittance) controls, and it is not a benefits guarantee or medical, billing, tax, or financial advice. It assumes a covered, in-network service unless marked otherwise, and does not model non-covered services, prior-auth denials, copay-then-coinsurance stacking, separate Rx/dental/vision accumulators, embedded vs aggregate family deductibles, secondary insurance, or HSA/FSA offsets; the deductible, coinsurance, copay, and OOP-remaining values are dated reference data you enter from the plan or a 270/271 eligibility response.
Authorities cited
- Standard cost-share adjudication ORDER: the plan applies the contracted allowed amount, then the deductible, then coinsurance or copay, capped at the out-of-pocket maximum (after which the plan pays 100% of allowed for covered in-network services). This is the order used on a payer EOB / remittance advice.
- Allowed amount vs billed amount: an in-network provider contractually writes off (billed - allowed); the patient is not responsible for that write-off. Out-of-network providers may balance-bill the difference. (CMS / standard insurer EOB terminology.)
- Federal No Surprises Act (Pub. L. 116-260, Division BB; 45 CFR Part 149, effective 2022) - limits balance billing for certain out-of-network emergency and facility-based services. Confirm applicability before billing an out-of-network balance.
- ACA out-of-pocket maximum: cost-sharing for in-network essential health benefits accrues to an annual OOP max set yearly by HHS (45 CFR 156.130). The REMAINING OOP-max value is plan/patient-specific and entered by the user as reference data - this plugin does not hardcode the annual statutory limit.
- Eligibility & benefit accumulators (remaining deductible / coinsurance / OOP) are obtained from the plan card, the payer portal, or a real-time X12 270/271 eligibility response as of a date the user records; they change as the patient incurs claims through the plan year.
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Estimate cost-share now
Run the estimate in your browser with nothing uploaded to anyone's cloud. Save the structured result to Sandbox, attach it to a Worklog patient-billing case, or route it into a Gate portal to share with the patient.