Medicare Out-of-Pocket Exposure Modeler

Medicare pays most of the bill, but the part it does not pay has no annual ceiling on the medical side unless you carry a supplement or an Advantage plan. This modeler walks a year of utilization through the actual 2026 cost-sharing rules, benefit period by benefit period, and shows what a routine year, a rough year, and a worst-case year each cost you.

Your Coverage & Utilization STEP 1

Coverage structure Determines whether a ceiling exists

IRMAA tier Sets the Part B premium

Hospital benefit periods this year A new period starts after 60 consecutive days out of a facility

Inpatient days per benefit period

Skilled nursing facility days per benefit period Days 1 to 20 are covered in full

Medicare-approved Part B charges for the year ($) Doctor visits, outpatient, imaging, therapy, durable equipment

Annual drug cost ($, plan-negotiated)

Part D plan deductible ($)

Medigap or Advantage monthly premium ($) Enter 0 if none

Advantage maximum out-of-pocket ($) Only used on the Advantage structure

Advantage medical coinsurance (%) Only used on the Advantage structure

Constants Panel EDITABLE

2026 Part A deductible per benefit period ($)

2026 Part A coinsurance, days 61-90 ($/day)

2026 lifetime reserve day coinsurance ($/day)

Lifetime reserve days available (once per lifetime)

2026 SNF coinsurance, days 21-100 ($/day)

SNF days covered in full

SNF days covered per benefit period

2026 Part B annual deductible ($)

Part B coinsurance after the deductible (%)

2026 maximum Part D deductible ($)

2026 Part D out-of-pocket cap ($)

Monthly Part B premium by tier ($, comma-separated, 6 tiers)

Monthly Part D IRMAA surcharge by tier ($, comma-separated, 6 tiers)

Medigap Plan N visit copay ceiling ($)

Assumed average Medicare-approved charge per visit ($)

Worst-case benefit periods

Worst-case inpatient days per period

Worst-case SNF days

Worst-case Part B and drug multiplier

Rough-Year Total Exposure

Including premiums, this year as entered

Monthly Budget Equivalent

Rough-year total divided by 12

Annual Ceiling

Rough Year, As Entered

Part A inpatient cost sharing--

Part A skilled nursing cost sharing--

Part B deductible and coinsurance--

Part D cost sharing after the cap--

Medical out-of-pocket after coverage structure--

Annual premiums including IRMAA--

Total out-of-pocket excluding premiums--

Total annual exposure including premiums--

Monthly budget equivalent--

Annual ceiling--

Lifetime reserve days consumed--

Three Scenarios

Routine-year total--

Rough-year total--

Worst-case total--

Exposure spread--

This compares projected annual cost only, not networks, formularies, or provider access. Plan details vary by county. Confirm with the plan and your State Health Insurance Assistance Program before enrolling.

Policy Mandate v2.0 · what is this?

Medicare Out-of-PocketExposure Modeler

Medicare Out-of-Pocket
Exposure Modeler