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A Real-Life Example

Are you confused about Marketplace terminology? Are you unsure about the financial impact of the plan you choose? Here is an example of how the different costs might interact:

You enroll your family in an insurance plan, and the coverage starts in January. On January 1, you pay your monthly premium of $100. You will pay this same amount every month for the rest of the year. In February, you visit your doctor because you have knee pain that makes it hard to walk. This visit has a copay of $30. The doctor prescribes a drug to help with your pain. The prescription has a copay of $20. You have now paid $50 towards your $1000 annual deductible.

Unfortunately, the prescription your doctor gave you in January doesn’t work as well as you’d hoped, so you return for a second visit, which means another copay of $30. You have now paid $80 towards your deductible. This time, the doctor takes an x-ray and orders an MRI scan. The x-ray is $300 and the MRI is $1200, for a total bill of $1500. Because you’ve already paid $80 in out-of-pocket costs, your deductible is now $920. This is the amount you will be required to pay for the x-ray and MRI. The insurance will pay the remaining $580 ($1500 - $920 = $580).

By paying the $920, you have now met your deductible for the year, so the insurance company will start paying for most of the care you receive the rest of the year.

After your x-ray and MRI, the doctor determines that you have an infection in your knee. You’ll need to have surgery, and maybe spend a day or two in the hospital. The surgery and hospital stay cost a total of $7000. Your insurance plan has a co-insurance rate of 20% for these services, so you will be responsible for $1400 and the insurance plan will pay the remaining $5600.

Thankfully, the surgery worked, and you’re back to enjoying all the things you used to do before your knee trouble started. You continue to pay your $100 premium every month, but are healthy the rest of the year.

Learn more about the terminology used in this example here.

Free help is available from BJC HealthCare

Call 314.747.4994 or 855.747.4994 from 8 a.m.-5 p.m. to make an appointment with a Certified Marketplace Counselor.

4901 Forest Park Avenue
St. Louis, Missouri 63108
314.286.2000
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