Enter the plan’s OOP max, the amount accumulated and this claim’s patient share to see what the patient actually pays once the cap applies.
The cap on everything
The out-of-pocket maximum is the ceiling on a patient’s year: once deductibles, copays and coinsurance accumulate to it, covered in-network services are typically plan-paid in full. Late in the year this cap silently rewrites estimates — a $300 calculated patient share can really be $150, or zero. Enter the plan max, the accumulated amount and the uncapped share, and this calculator applies the cap.
How to use it
- Enter the plan’s out-of-pocket maximum.
- Enter the amount accumulated year-to-date (eligibility verification).
- Enter this claim’s patient share before the cap.
The logic
A worked example
A $6,000 max with $5,850 accumulated leaves $150 of room. A claim carrying a $300 patient share collects only $150 — the plan absorbs the other $150, and the patient’s max is now met: subsequent covered services run 100% plan-paid. Collecting the full $300 here creates a refund, which is why the OOP check belongs in every late-year estimate.
Estimates only — payer contracts, plan documents, published fee schedules and the EOB are the source of truth, and nothing here is billing, legal or medical advice. The calculator runs entirely in your browser: no patient data is entered, transmitted or stored.