How to Estimate What You'll Spend on Health Care

For many people, it's the main question about health insurance: How much will it cost me? 

It all depends on the health plan you select, how often you get care, and what kind of care you need. But you can make some reasonable estimates.

Four Ways You Pay

1. Premium. This is what you pay your insurer each month for coverage. It is the most predictable cost you'll have. The amount depends on the particular health plan you select. Multiply your premium amount by 12 to get the yearly cost of your health plan.

  • Typically, the more you pay in insurance premiums, the less you pay in out-of-pocket costs each time you go for medical care.
  • The opposite is also true: The lower the cost of your health plan each month, the more you pay each time you need health care.

2. Deductibles. This is part of your out-of-pocket costs. A deductible is a set amount you must pay before your insurance company helps to pay toward your care. It may be $500, $1,000 or more than $7,000. 

  • Some plans may have an overall deductible. That means you may need to pay the full cost of doctor visits or medical care you receive until you reach the deductible amount. After you do, the health plan starts paying its portion of covered services. At that point, you will pay for part of your care in the form of copays, co-insurance, or both as outlined by your insurance policy.  
  • Some plans may have different deductibles for different types of care. For instance, the plan might start paying toward your health care sooner if you see in-network providers. For care you get from out-of-network providers, you may need to pay a higher deductible before the plan starts sharing the cost with you. Some plans may have one deductible for medical services and another for pharmacy benefits.
  • You can generally get certain types of preventive care without having to first meet your plan’s deductible or pay any other costs.

3. Out-of-pocket costs in copayments or co-insurance. How much money you'll spend also depends on how many times you see doctors, buy prescriptions, and receive other types of health care services. For each visit or drug, you may have a copayment or co-insurance.

  • Copays are a flat fee, like $15 for a doctor visit.
  • Co-insurance is a percentage of costs that you pay, such as 30% of a prescription drug cost.

4. Care and supplies that aren't covered by insurance. You'll have to pay the whole cost for services or products that your health plan doesn't cover. These costs may include:

  • Over-the-counter medicines
  • Vitamins and supplements
  • Acupuncture or chiropractic care
  • Fees for providers that are not part of your plan's network

 

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How to Estimate Your Costs

How often might you see a doctor or need medicine? An educated guess can help you predict these needs -- and what you'll pay for them. Here are some steps to take to help you figure out how much care you might need going forward.

Look back on past expenses. If you keep medical receipts, go through them. Add up your costs for doctor's visits and medicines. Or ask your doctor for a history of your payments over the last year. Your drug store may have a record of your payments for medicine, too.

Use an online calculator. Some web sites -- including this one– and some web sites that sell insurance -- can show you estimated insurance costs. If you have employer insurance, your company may offer a tool to estimate costs.

Anticipate your family's health needs.Yearly checkups for children and immunizations are free, but you will have to figure in costs for treating chronic conditions like high cholesterol and diabetes, doctor appointments, and medicine. 

Other expenses might include counseling for mental health and planned surgeries or medical procedures that you might have to share in the cost by paying a co-pay or co-insurance.

 

Ways You May Pay Less Under Health Care Reform

Changes now in place as a result of health care reform may lower your costs.

Out-of-pocket cap, also called an out-of-pocket maximum. If you're buying a plan from your state's Marketplace (also called an Exchange), health care reform puts a limit on your out-of-pocket costs. For 2017, the most you will pay out-of-pocket for services your health plan covers is $7,150. A family will have to pay double that -- $14,300.  Your deductible will count toward this cap, but your monthly premiums will not. Co-pays and co-insurance also count towards your out-of-pocket maximum. Those numbers may look very high. But they at least put an upper limit on what you'd have to spend.

Free preventive care. Under health reform, you'll have no copayment, co-insurance, or requirement to meet your plan’s deductible for new baby care, well-child visits, screenings for early signs of disease, like mammograms, and many other services when you receive care from a provider that participates with your health plan. The exception to this requirement is for grandfathered health plans, those in existence before health reform was passed that have not experienced significant changes. 

WebMD Medical Reference Reviewed by Sarah Goodell on September 16, 2016

Sources

SOURCES:

Cancer Action Network: "New Study Reveals Popular Federal Employee Health Plan a Good Starting Point to Determine Minimum Benefits Coverage."

Consumer Reports: "That CT Scan Costs How Much?" and "Update on Health Care Reform."

DukeHealth.org: "Medical Bills Force Patients to Skimp on Care and Necessities."

FamilyDoctor.org: "Health Care Reform: What It Means For You."

Healthcare.gov: "Insurance Basics" and "Women and the Affordable Care Act."

Kaiser Family Foundation: "Survey of People Who Buy Their Own Insurance."

Kaiser Health News: "Study: One Third of Individual Plans Exceed the Law's Out-of-Pocket Gap."

Milliman: "2012 Milliman Research Report."

National Association of Insurance Commissioners & The Center for Insurance Policy and Research: "Health Care Reform Frequently Asked Questions."

Urban Institute: "Health Insurance Coverage of Young Adults."

Center for Medicare & Medicaid Services. 

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