Hypothetical Medical Bill Breakdowns
Just a disclaimer: This article includes assumptions and guestimating of medical costs. The purpose of these examples is to simplify how insurance companies work and how insurance terminology translates into common medical situations.
These examples don’t factor in many things like: out-of-network doctors, having different deductibles and coverages for out-of-network expenses, or various other uncovered bills. These are very rudimentary examples.
My Family of Wimps
Situation:
Your wife and two children each go to the doctor for 1 sick visit and 1 general check-up each year. Of course you didn’t get sick because you’re a bad ass. Each visit costs $400. Times this by 3 people and 2 visits per year, for a total of $2,400. But that’s not what you actually pay. Your plan has a doctor visit copay of $75, so you pay just $75 upfront for each of these 6 visits.
Your health insurance plan has a…
of $5,000
coinsurance
of 20%
copay of in-network doctor
of $75 for “routine care visits.”
out-of-pocket maximum
of $12,000
You Pay
450
$75 copay
X
6 Doctor Visits
=
$450
My Family of Wimps (Version #2)
Situation:
Same situation as the previous example except your insurance plan doesn’t have a copay. You pay the full amount for these visits.
deducticble
of $5,000
coinsurance
of 20%
copay of in-network doctor
of n/a
out-of-pocket maximum
of $12,000
You Pay
2,400
$400 per visit
X
6 Doctor Visits
=
$2,400
SuperHero (You) Breaks Leg
Situation:
You didn’t get sick all year but you broke your leg. You were probably running a marathon or saving a family from a burning house. Medical bills for this emergency totalled at $7,000.
deducticble
of $5,000
coinsurance
of 20%
out-of-pocket maximum
of $12,000
You Pay
5,000
You Pay
400
(20% of the remaining $2000 after you pay your deductible)
$5,000
+
$400
In addition to your monthly premiums, other deductibles (surgical, etc) and any applicable copays, this example accident would cost you $5,400.
“Firework” Accident
Situation:
You didn’t get sick all year but you were in a serious accident with a firework. (We won’t ask.) Surprisingly your medical expenses reached $50,000 the few days you were in the hospital.
deducticble
of $5,000
coinsurance
of 20%
out-of-pocket maximum
of $12,000
You Pay
5,000
You Pay
7,000
(20% of the remaining $45,000, reduced by $2000 because it exceeds your out-of-pocket max)
You Pay
0
$5,000
+
$7,000
In addition to your monthly premiums, other deductibles (surgerical, etc) and any applicable copays, this example accident would cost you $12,000 because you reached your annual out-of-pocket maximum.
Types of Insurance Plans