Essentially, what I'm looking for is a simulation of out-of-pocket cost as a function of a health insurance plan and an arbitrary sequence of medical events -- in other words, a computational model of how an insurance company processes claims. Does this exist?
Out of pocket medical costs is relatively easy to calculate. You should be able to use the following formula.
Annual Premiums + Policy Deductible + Policy Co-Insurance = Maximum Exposure
As far as how an insurance company processes claims.
(Full billing amount - % of network contracted rate) - remaining deductible/coinsurance = Insurance Company Responsibility.
So an example:
Mary goes to the doctor and has a procedure that the full cost is $500. She went to a network doctor and the insurance company has a 10% discounted rate with that particular provider. That brings the total bill to $450. Mary still owes $200 on her deductible and has a co-insurance of an additional $1000 at an 80/20 ratio.
- $450 - $200 = $250 After deductible is paid.
- 80% of $200 is $160. This is the insurance companies portion.
- Mary had to pay $200 due to her deductible and $40 due to her co-insurance.
- Mary's responsibility is $240.