If you have private health care coverage, what sort of out-of-pocket costs would you normally have to pay within your system?

I have had 4 surgeries in 3 months, and the bill was over a half million dollars. My portion was $1,500, which is the annual out of pocket cap for me.

Great question! Really looking forward to answers.

Mine (to the best of my memory)

I have a $600 deductible for me, I believe it’s $2000 for the family as a whole. I pay just about everything before I reach that number at insured rates.

After that.

Doctor Visit: $20 copay if covered, some odd things aren’t (flu mist was $45)
Hospital: $50 copay, unless ER, then $100 copay
Surgery: Paid at 80% even before deductible. I’ll have to ask my wife how this works exactly, I just know we’ve been responsible for 20% of surgery costs in the past.

Not sure what our yearly max is, I guess we haven’t hit it.

We pay ~$600/mo for insurance on our family of four, subsidized by my wife’s employer, who’s a major healthcare provider. Our healthcare costs this year, with a pregnancy, birth, and emergency surgery will be ~$10k.

I pay $25 for visits to the doctor and $15 for prescription medicines. If I need hospitalization, I will pay 10% of any bill. I do not know if I have an out-of-pocket cap to what I might have to pay.

I work for the state and have superb insurance that I pay a high premium for. I know that many health care providers like my insurance a lot.

I also have dental insurance and a vision plan.

I must add that $15 for medicine is fantastic. I know one of my pills cost $900/month.

I have an HSA that I contribute to. The plan is high deductable and after ~2k it’s 80–20. the max out of pocket is like 6k. Costs me ~25 bucks a month. I get regular checkups free. Good plan if you are young and healthy. The HSA lets me stockpile what would go into premiums for a better plan.

Thank you everyone. I’ll come back later and respond in more detail. I’m trying to understand how our system compares (the health insurance component).

GP: $10.00
Specialist (non-gyn): $20
ER: $50 (waived if admitted)

My prescriptions are separate from my health insurance. I take 4 psych meds, 1 asthma pill, 2 inhalers. The most money is spent on my Pro-Air inhaler ($32.00), but my other meds are as low as $3.20. Everything is very affordable.

Note: My insurance is through my wife’s job with the LAUSD and LAUSD benefits are crazy good. Their teacher’s union has fought hard for those benefits. Everyone in So-Cal knows about the great LAUSD benefits. Nothing comes out of her paycheck for medical insurance.

I have a $15 copay to see a specialist, no copay for my PCP. My most expensive prescription is $15 a month, the rest are single digit dollar amount per month (my birth control is free!)

My insurance covers all but the first $1000 annually, and my company actually covers the first $500 of that. I barely paid out of pocket this year.

I opted for the “Cadillac” plan from my employer; it is about $100 a month for me. I am somebody for whom this is very much worth it.

Insurance: free. Copay: 20 per visit. Can be 20 extra for x-ray.

Generic drugs: free. Non-generic: Not sure, maybe 20 bucks or of course, if it’s cheaper, than I pay the cost (for example, Costco has some medications pretty cheap).

ER visit: 40 bucks copay.

I have dental and vision plan. If I use certain providers, it’s free. If I use my own eye doctor or dentist, I front the money and get reimbursed a pittance. Maybe 27 bucks for a cleaning, 82 bucks annually toward contact lenses, 95 bucks annually toward eye exam.

Mammogram is free and I get 4 hours off annually to have one.

Fairly crummy COBRA plan (pick-up from company insurance.) Pay $614, a month. $1500 annual deductible in network which I haven’t reached and $3,000 deductible out of network.

Will be on Medicare soon which will still be expensive but much better coverage.

I’m in America. I think we have an annual family deductible of $4k. So the first $4k I pay. That includes doctors fees, lab test, any sort of diagnostics like X-rays, and prescription meds. After that I think I pay 20% (might be 30%) of the fees, but the fee price is often inflated. It’s horrible.

I participate in an HSA account, which is basically a savings account that is tax free, and I use that money for all medical costs. My income is taxed at about 30% so that’s a decent savings at least.

I don’t know what we are paying now for insurance. We just got off of COBRA and that was $800 for couples insurance. If I had taken obamacare it would have been $500. I don’t know what we were paying when my husband had his job with that insurance, I think it was around $200 a month. The company before that it was free for us, the company paid for insurance for employees at his level, he was a VP. Of course, people at lower levels making much less had to pay.

20%

I pay everything until $5000, then I pay 10–20% (depending on the provider) until I hit max out-of-pocket, which is $8000.

When I say I pay everything, that includes medication (so medication is the full-price negotiated by my insurance company until we hit our deductible) but excludes preventive care (checkups, immunizations).

I pay $20/month for my premium and contribute $5000 into my family HSA account.

In my area, there are precious few copay plans available and they are usually priced very high.

@Cupcake Thank goodness HMO plans are being fazed out. I think they greatly contributed to the mess we have today.

@JLeslie I have mixed feelings. My health plan is unaffordable for most people, since you could be hit with a multi-thousand dollar bill in the beginning of the year. Fortunately for us, we have built up our HSA over years and can cover a max-out-of-pocket year, if necessary. But we also put health care costs on a credit card (NEVER do that!) before we built up our HSA.

There are many people who avoid medical care in the beginning of the year and many people who are quick to make health care appointments when they have “free” health care at the end of the year.

Well, our premiums are about $400 a month. When we file a claim, insurance pays for 90%.

@Cupcake I understand your point, but HMO’s created an environment where medical cost were under the radar. No one really knew (or more accurately no one cared) how much their insurance was paying doctors, or how much insurance companies put in their pockets. Not at first. If your doctor ordered tons of unnecessary blood work and it only cost you the same $20 did you worry about it? Most people didn’t. Then we all start paying higher and higher premiums to cover those costs.

Add in employers paid part of the premiums, we are even more clueless. It’s like a secret society. Trust me, a lot of the time the decisions makers in companies are good ol’ boy friends with the guy selling the particular health insurance and suddenly your company switches from BCBS to Cigna administering your policy. Not every company was doing deals because of discussions at the 19th hole over drinks, but more than people think.

Furthermore, HMO’s put significant limits on who you could see for your medical care and a horrible dance if having to see a primary first for everything. I hated it.

My husband’s last company fazed out HMO coverage while they were there and their analysis showed people who made the lower wages chose HMO’s and would be most affected by their change in insurance choices. During discussions with employee what came out was the people on the tightest salaries wanted to be able to predict their monthly expenses. Not everybody of course, but they heard that a lot, and the executives didn’t anticipate that to be the reason. They weren’t even doing the math, just wanted the regular payment. I also hypothesized a lot of them were probably younger employees and grew up on HMO’s.

I think the trick is, if your premium is now lower, stash the balance away. With HSA accounts it’s a tax free stash. At first they did FSA a counts and that was theft in my opinion. It’s disgusting anyone thought of it or pushed it like it was a good idea.

What do you mean free health care at the end of the year? Maybe the first year people wait because they need to build up their HSA, but the average person with average bills would actually be best waiting until the next year, January, if they can, and use up their deductible within one calendar year if they are going to use it up. Although, I don’t promote waiting to go to the doctor if someone actually is sick, but well care visits you can sometimes smush into one year by doing them at the 13th month mark and then other well visits within the same calendar year.

@jleslie I agree with you about FSAs and hidden expenses.

Only people who have the money to pay for the deductible benefit from waiting for the next year. Otherwise, the health care is “free” if you’ve met your max out-of-pocket or “cheap” if you’ve met your deductible, which means a disproportionate amount of care is provided at the end of the year… and disproportionate amount of care in the beginning of the year is higher acuity. I’m not saying it burdens the health care system, although it might. But I’m saying that the stress of considering the differential pricing of health care throughout the year is a burden that effects health and may prevent or delay people from obtaining (free) preventive and sub-acute care throughout the year.

Predictability of health care costs is so highly desired that people lose out on health care money by having expensive copay plans instead of HSA plans. I see it all the time. Some of the poorest people I know have expensive copay plans. I save money by having a relatively cheap HSA plan… but I’ve had it for years and rolled money over every year. So I could afford the cheap plan in that way. It’s like Costco… I can afford the annual membership that I use to save money. People who don’t have extra money for a membership or for a bulk pack of TP pay far more for their toilet paper per roll than I do. It’s just another example of how rich get richer and poor get poorer. But in this case, they are actually getting sicker by worrying about how to pay for their medical expenses at the beginning of each year.

Deductibles should never be more than the IRS maximums for HSAs. I think that should be a crime.

@Cupcake I’m confused (not being argumentative) can you explain again in different terms why people wait to the end of the year for healthy care or even wait to address problems on high deductible plans? Are you saying if they don’t meet their deductible they don’t even go in for the care? They wait until illnesses and necessary care get them past their deductible. Some healthy care is free even with high deductible plans.

Your point about deductibles not being allowed to be higher than maximums for HSA’s is a valid point. I hadn’t thought of it before. Although, along with that can’t people elect to put nothing into an HSA? Or, are they forced to?

@Cupcake I want to add I hate the deductible system (I sound like a broken record). If we don’t have a socialized system I’d prefer a 50/50 system with a cap for out of pocket fees. It sucks to start from zero again at the beginning of every year for a deductible.

@JLeslie You can put nothing into your HSA.

Here’s an example:
January: “I don’t feel well. I don’t want to go to the doctor because I would have to pay full price. I already have to pay $200 this month for my antidepressant.”
February: “I broke my leg, so I must go to the doctor. I’ll go there because it will cost less than the Emergency department or Urgent Care. Oh no… my doctor is sending me for x-rays. How could I be so stupid? Now I have to pay for two visits and films. How can I ever afford this?”
March: “My anti-depressant isn’t working well enough. Maybe I can just email my doctor so that I don’t have to pay full price for a visit.”
April: “Now I’m so depressed and stressed about money that an email won’t suffice. I have to see the doctor.”
May: “Since it took me months to see my doctor over worry about the price, I am really not doing well. I can barely get out of bed to go to work. I might lose my job. The new medication is now $1000 per month. At least I’ll meet my deductible next month…”
June: “Yay! I finally met my deductible. Now maybe I should go see the doctor about the wart on the bottom of my foot that I’ve been ignoring.”
July: “I wonder if I’m depressed because of my thyroid. I should get it checked out now that I’ve met my deductible.”

I’m sure it’s a terrible example. I’m not going to re-read it.

The point is, people will seek care for what is urgent when they have to pay full-price. Ignore preventive medicine (although some people confuse the two and think they have to pay for those visits too even though they would be free.). If you have a deductible plan, you’re not going to the doctor in January over a wart.

Then comes December. Get your blood work done. Get that x-ray you’ve been postponing. Finally get that chronic hernia surgery. Realize that your acid reflux really is more of an issue that you thought. Whatever it is that you could have lived without doing… now you can address it for free (or almost).

The fact of the matter is that most Americans live paycheck to paycheck. And many do not understand the nuances of preventive care. So if you’re struggling to pay for health expenses, or you’re worried about covering the full cost… you’re probably not signing up for that colonoscopy or getting that bloodwork or whatever until you’ve met your deductible.

@Cupcake I agree with your example. I do it myself to some extent and I can afford to go to the doctor. The system creates an environment where pts try to game the system as well as they can. Although, I will say the thing that bothers me most is having to go to my doctor for a blood test or blood test results if my medication change is basically adjusted according to blood results for chronic illnesses. I think they should get $5 or $10 for looking at the results and calling/transmitting in a script, but not $100 for a visit and make me drive 45 minutes round trip and wait in their office. There are reasons when coming into the office is prudent, but there are also reasons when it is unnecessary. This is why I think doctors should be paid more on an hourly basis or salary. Let them get paid for a phone call, let them get paid for reviewing tests, but don’t waist my time and money to be able to charge something.

It really depends on your employer. It actually depends on what health plan you have, but since many employers pay a substantial portion of the insurance premium as a non-wage benefit, most Americans have whatever coverage their employer offers. Each plan has a different out-of-pocket maximum, but also enough exemptions in coverage that actual costs may exceed that. This in addition to the premiums themselves, though most don’t think of that as “out of pocket” since it’s usually done by payroll deduction.

To show you how steep it can be, I used to have a plan with a high deductible ($1,500 per person; $3k max per family) combined with an HSA that my employer put $1k into every year to partially offset that deductible. Every two weeks, my employer would take about $50 from my check for premiums. After being terminated from that job due to my medical leave expiring with no estimated date of return from my doctor, they offered to let me keep that coverage, but I would have to pay the entire premium out of pocket.

I think that now would be a good time to mention that my employer paid 90% of my premium; retaining that coverage under COBRA would’ve cost me just under $1,000/month. To put things in perspective, that’s about two weeks net pay for someone earning 42–45 hrs/wk at $17–18/hr, or an entire month’s pay for a part-timer at a more modest $12–13/hr. So whatever out-of-pocket expenses you have for co-pays and meds is in addition to premiums; without employer subsidization, that can be about $12k/yr easily.

What gets covered and how far also varies by plan. When I had my car accident, my auto insurance maxed out on my ER bill, leaving the ER doctor’s bill, radiology, followup visits, and physical therapy on me and my health insurance. That was a couple of grand right there as it was early enough in the year that I hadn’t met my deductible yet. Were it not for the fact that I had an excellent (employer subsidized) short-term disability plan in addition to lost wage coverage on my car insurance, I would’ve been totally fucked.

Meds may or may not be covered. Even on Medicare/Medicaid, there are some out-of-pocket expenses. I’ve declined to fill uncovered scrips that were over $400 due to the simple fact that I didn’t have the money.

To sum up, even for someone moderately well-off who has multiple layers and forms of coverage, it’s pretty easy to spend many thousands of dollars a year, and those who don’t have the thousands to spare generally wind up paying at least ten times as much as those who do.

Thank you so much to everyone for their answers. I’m going to go through them more carefully later. I was interested in the additional costs most US private health consumers are responsible for. We have a quite complex system in Australia and I wanted some comparative information.

For those who are interested, I will explain the system here. This will be long. Sorry about that. For some this will definitely fall into the TL:DR category.

We have universal healthcare in Australia, but increasingly the government ‘encourages’ us to take out private health insurance as well. I refuse, since the private health care system is so flawed and is a rip-off.

How our system works is the government deducts 2% of our pay as our contribution to our national health care system Medicare. All people who are paid an income contribute. If you earn over AU$90,000 they take another 1–1.5% to contribute to Medicare. I don’t have a problem with this. I earn it, I can afford it, and everyone benefits. This additional 1–1.5% is not charged if you take out private health insurance. So the government is ‘encouraging’ people to take out private health insurance.

Other ways the government encourages people to take out private health insurance is by making private health premiums tax deductible. I don’t have a problem with this. So if you pay private health insurance, you can claim those premiums as a tax deduction.

However, if you don’t take out private health insurance until you’re 31, the government applies a loading to your premiums. This is 2% if you take out private health insurance at 31. At 40, the loading will be 20%. By 50, it’s a 40% loading. This loading also applies if you have private medical insurance and then for some reason drop it prior to the age of 31 and then reinstate it a few years late. You will still have to pay this government-imposed loading. This is to compel young people to take out private health insurance.

Again, you could say that’s fair. You haven’t been paying your premiums for so long. However, I don’t think the government should be forcing people to buy the services of privately-owned companies and especially when those companies aren’t providing a quality service.

In addition, up until this year, if I choose to pay to have a procedure carried out privately, I could claim the costs of that back on my tax once I reached a particular threshold. However, the government has now canned that. So if I choose to pay to have cataract surgery through a private hospital, with a specialist of my choice, I can’t claim back any of the costs over and above the standard Medicare rebate. This will leave me significantly out-of-pocket. Even though I’m helping the public system by not clogging up the queue there.

The problem I have with private healthcare here is that there is so much it doesn’t cover. See the previously cited news article. So if I have a baby under the public health system, I go to hospital, have my baby, leave the hospital – no bill. I won’t be able to choose who delivers my baby, and after I reach a certain point in my pregnancy, I’ll need to attend a hospital clinic and won’t get to choose who I see. I’ll have to wait longer for appointments. I’ll have to share a room with other mothers after the birth. I had my first child through the public system and was able to see my local GP until I was about seven months and that was fine. Cost to me to have my first child $0.

If I have private health insurance, I can choose the doctor I see. That doctor will usually have their own preferred private hospital setting. They will work with an anaesthetist etc. The government will fund a portion of the cost of this care through Medicare. There will be a gap between what the government pays for the hospital, doctor, anaesthetist, labor ward etc. Part of that gap will be paid by my private health cover. The rest will be billed to me. I’m going back a long time, but my out-of-pocket costs for my second daughter were $2500.00 plus my monthly private health contributions. I had top hospital and extras cover at the time. I recall needing some pain relief, so they brought me a box of pills. I took two. They billed me for the whole box.

The third option is to use intermediate care. I choose my doctor, and as with the private option, they will usually specify the hospital/anaesthetists (if required), labor theatre etc. The government will pay a set amount to the doctor (the Medicare component). I will pay then pay the difference between the government contribution and the doctor’s bill. The same would be true if an anaethetist was involved. I will also pay the nightly accommodation charge at the hospital. The government will pay for the labor ward. For my third child, total cost was $2500 with no monthly contributions to a health fund.

So, to sum up, because private health care here does not cover the gap between what the government will contribute and doctor charges, and because health care here doesn’t cover a number of the elements relating to health care procedures, patients can be left with horrendous out-of-pocket fees. Fees they have no control over and often no awareness of. They just find themselves billed after they have received the treatment.

Given the US system is so driven by private health providers, I was interested in whether you have this ‘gap’ problem. It would seem based on a quick scan of the information above, that you do not. You pay your monthly contributions and there is often a set amount you may need to pay in addition to those premiums if you need to seek medical treatment. You have a set ‘excess’ fee that you are aware of.

I don’t have to take out private medical insurance, and given the situation here, I totally refuse to do so. I wouldn’t pay an insurance company to insure my car with the understanding that should I have an accident, the repairs would then potentially cost $$1000s and the insurance company would only pay a small portion of the costs. I dont’ see why I should do that for health insurance.

I have known people who have developed kidney disease or cancer, who have been advised by their medical provider to ditch their private medical insurance immediately. If they don’t the out-of-pocket costs will send them bankrupt. Other “news coverage“http://www.sbs.com.au/news/article/2015/03/30/explainer-why-do-australians-have-private-health-insurance

If people want to take out private health insurance, that’s fine. However, they shouldn’t then be hit with horrendous bills because there’s a huge disparity between what the doctors charge, the government will contribute and their health fund will cover.

Plus, if they choose to pay for private treatment rather than using the public system, they should be able to claim a rebate. That’s now been cancelled from this year. So your options are:-

Go public – which can mean a longer wait.
Take out private medical insurance – still pay additional costs over and above your premiums (and this can be a significant cost).
Pay yourself and have no option to reclaim any of the costs that exceed the Medicare payment.

And private health here doesn’t equate to better. My husband had surgery in a private hospital, with a private specialist and the service was terrible. The nurse admitted they were operating on a skeleton staff to cut operating costs.

So thank you for providing me with a clearer understanding of the US system. My main problem is that governments are pushing people to take out private health insurance, but they aren’t then making sure that the service provided is fair and reasonable.

Ran out of editing time. Apologies for typos etc. in post above.

@Earthbound_Misfit Thanks for providing more details about this. I didn’t read the entire post very closely, but from some of what you’ve said, I suspect many of these aspects appear in the Canadian system as well. The difference is that (I believe from my experience and those around me, but would have to look up numbers) most people never bother with the private care, so never experience the gaps you talk about. You mention longer wait times for Medicare-arranged visits, but I’ve never experienced any delays that seem unreasonable to me.

But yes, I think that choosing private health care (which is more or less considered a luxury) would come with the risk of all kinds of charges that are not regulated or paid for by Medicare, and the patient would have to carefully assess whether their coverage is sufficient for what they want to have done.

Again, some of these things vary from province to province, and so few of us can compare more than two or three provincial systems from personal or second-hand experience.

@Earthbound_Misfit Don’t forget that the US has higher costs to begin with before any form of insurance enters the picture. Does the Australian system charge $40 or more per tablet of Acetaminophen? How about $900 for an MRI? And that is for just the MRI; if you have a doctor look at it and enter any findings into your record, that’s a couple hundred more dollars on top of what you’re paying for the doctor that actually treats you.

I think that the price scale here makes our system even more different from what Aussies (or practically any other civilized nation on Earth) have.

@jerv, I’m not sure the costs in the US are higher or lower for specific procedures/medicines. I found a site that said an MRI would cost up to $500. No idea if that’s right. You’d also still have to pay for the consultation etc. etc. A Google search says Acetaminophen is the North American term for paracetamol. A packet of 100 brand name paracetamol tablets is AU$10.99. Why is paracetamol so expensive in the US @jerv? I know it’s even cheaper in the UK.

I’m not so much concerned about the cost @jerv. I don’t pay for private medical insurance. What bugs me is that people are paying for insurance that doesn’t cover many aspects of the required care and treatment and they then end up with an unexpected, and sometimes very large, bill. If you’re going to pay for insurance to cover a risk, you want to know how much of the risk it will cover and what you will have to pay out if the event happens. Getting cancer and finding out your insurance doesn’t cover many of the costs you incur is wrong. I object to my government encouraging people to pay health insurance that doesn’t cover the cost of treatment. I’m fine with a clearly expressed excess amount. If people know upfront, if you get sick, you’re going to have to pay $$ of any costs. I object to the lack of clarity around what people will be charged and will have to pay over and above their insurance premiums.

If you found an MRI that cheap, then I am shocked and amazed.

It really isn’t…. usually. Tylenol (Paracetamol) is about the same price here if you buy it over the counter; about $10 for a big bottle of ‘em. But the fact that it’s given to you at the hospital jacks the price up a few orders of magnitude because ‘Murica.

I am fairly certain that even if you Aussies get treatment that isn’t covered, your out-of-pocket expenses would be significantly lower than mine for the same treatment. Our system is even less clear than what you have there, and the costs are just totally different. You might find this informative, along with this set of charts that was linked to it. A slight spoiler; the hip replacement that cost us over $40k, you could get for under $28k, and other prices are similarly inflated.

@Earthbound_Misfit MRI is usually around $500—$2k but can be as high as $4k when the diagnostic center bills, and then that gets reduced to a lower “insurance negotiated price.”

If private insurance in your country causes a circumstance like what we have in America I feel badly for the Aussies. Maybe it won’t happen since you have a public system too.

Here is one example from insurance I had a few years ago: one of my thyroid blood tests is $15 if I pay for it with no insurance. If I go through my insurance the lab bills $127 to the insurance company. Then, there is a reduction for the insurance price (you see all this on a statement) to $60. Then my copay is $12. I’m rounding all the numbers. It’s $3 cheaper for me to go through insurance, but the lab made $60 instead of $15. It drives me insane. Most Americans don’t know the self pay price, they never ask. There are times when self pay is the more expensive option.

Pricing is very opaque here. You can be at the doctor’s office and the doctor can tell you you need something done, and if you ask the price there is a good chance he will say, “I don’t know, you have to call your insurance.” Or, you go to the doctor, he checks you over, and then you get a surprise bill for double what you expected, because the last doctor who did the same thing charged much less, but you have no idea at all that this doctor charges double.

Yeah, the “insurance negotiated price” makes any attempts at calculation by anyone outside of the billing department pointless. Case in point, my uninsured father-in-law spent a week in the ICU. The raw cost was ~$100k, but they gave him a discount for not having insurance that took it down by a third to “only” ~$67k.

@jerv Did you ever ask the self pay price? I assume with a bill that high you didn’t bother. I wouldn’t either, I’m just curious.

@JLeslie Not my circus, not my monkeys.