Cost Estimation

GET /v1/health/plans/:id/oop-estimate

Estimate out-of-pocket costs for a specific plan based on common healthcare utilization scenarios. The estimate uses the plan’s cost-sharing structure (deductible, copays, coinsurance, MOOP) to project annual costs.

Parameters

Parameter	Type	Required	Description
:id	string	Yes	Plan standard component ID (URL path)
age	integer	Yes	Enrollee age
year	integer	No	Plan year (default: 2026)

Example

curl

curl -H "Authorization: Bearer op_YOUR_API_KEY_HERE" \
  "https://api.opelyx.com/v1/health/plans/12345FL0010001-01/oop-estimate?age=35"

Python

import requests

plan_id = "12345FL0010001-01"
response = requests.get(
    f"https://api.opelyx.com/v1/health/plans/{plan_id}/oop-estimate",
    headers={"Authorization": "Bearer op_YOUR_API_KEY_HERE"},
    params={"age": 35},
)
estimate = response.json()
for scenario in estimate["scenarios"]:
    print(f"{scenario['label']}: ${scenario['total_annual_cost']}/yr")

JavaScript

const planId = "12345FL0010001-01";
const response = await fetch(
  `https://api.opelyx.com/v1/health/plans/${planId}/oop-estimate?age=35`,
  { headers: { Authorization: "Bearer op_YOUR_API_KEY_HERE" } },
);
const estimate = await response.json();
for (const scenario of estimate.scenarios) {
  console.log(`${scenario.label}: $${scenario.total_annual_cost}/yr`);
}

Utilization Scenarios

The estimate includes three utilization scenarios:

Scenario	Description
Low	Minimal healthcare usage — preventive care only
Moderate	Average usage — a few doctor visits, one specialist
High	Significant usage — chronic condition management, procedures

Each scenario returns the projected annual cost breakdown including premiums, deductible spending, copays, coinsurance, and the total annual cost.

How Costs Are Calculated

The estimation uses the plan’s Summary of Benefits and Coverage (SBC) data:

1. Premium — 12 months of the age-rated premium
2. Deductible — Applied first to all non-preventive services
3. Copays/Coinsurance — Applied after deductible is met
4. MOOP cap — Total out-of-pocket is capped at the plan’s maximum