Scenarios
The scenarios below are here to serve as helpful guidance for making decisions during Open Enrollment.
Scenario 1 (Primary care visit)
Avery is a 25-year-old working full time with employee-only coverage. Avery is in good health, having no major health issues or ongoing prescriptions needs. Avery goes to her Primary Care Provider (PCP) visit due to feeling weak and lacking energy. Avery is prescribed a prescription to address low iron levels.
| |
PPO |
HDHP |
| |
Service Provided |
Cost Incurred |
Service Provided |
Cost Incurred |
| PCP Visit ($180 total charges) |
1 visit (standard PCP copay per visit) |
+$20 |
1 visit (full visit cost until deductible is met) |
+$180 |
|
One Prescription Filled
($100 value)
|
1 prescription (standard copay for tier 2 medication |
+$10 |
1 prescription (full medication cost until deductible is met) |
+$100 |
| Annual Premiums |
$76.08 bi-weekly premium (x24 pay periods) |
+$1,825.92 |
$50.97 bi-weekly premium (x24 pay periods) |
+$1,223.28 |
| Annual Physical |
1 physical ($0 covered under preventive care) |
$0 |
1 physical ($0 covered under preventive care) |
$0 |
| Less Company-Provided HSA Money |
HSA not applicable with PPO Plan |
$0 |
Annual amount provided by Carle Health |
($250) |
|
Cost Summary (yearly total medical cost based on above scenario)
|
|
$1,855.92 |
|
$1,253.28 |
| Tax Savings Opportunity |
Flexible Spending Account |
Health Savings Account |
Scenario 2 (Lab draw)
Macen is a 32-year-old married person with a wife and three kids. Macen is going in for his basic lab draw done one week and a comprehensive lab draw done the next week.
| |
PPO |
HDHP |
| |
Service Provided |
Cost Incurred |
Service Provided |
Cost Incurred |
PCP Visit ($180 total charges)
(Labs Ordered) |
1 visit (standard PCP copay per visit) |
+$20 |
1 visit (full visit cost until deductible is met) |
+$180 |
| Basic Lab Panel ($211 cost) |
1 lab draw (standard lab copay per visit) |
+$50 |
1 lab draw (full standard lab cost until deductible is met) |
+$211 |
|
Comprehensive Lab Panel ($538 cost)
|
1 lab draw (comprehensive lab copay per visit) |
+$50 |
1 lab draw (full comprehensive lab cost until deductible is met) |
+$538 |
PCP Visit ($180 total charges)
(Lab Follow Up) |
1 visit (standard PCP copay per visit) |
+$20 |
1 visit (full visit cost until deductible is met) |
+$180 |
(Family Member: Dependents)
6 Trips to Convenient Care
($900- Total Charges) |
6 visits (standard convenient/ urgent care copay-$20) |
+$120 |
6 visits (standard convenient/ urgent care visit-$150) |
+$900 |
| Less Company-Provided HSA Money |
HSA not applicable with PPO Plan |
$0 |
Annual amount provided by Carle Health |
($250) |
| Annual Premiums |
$227.60 bi-weekly premium (x24 pay periods) |
+$5,462.40 |
$180.14 bi-weekly premium (x24 pay periods) |
+$4,323.36 |
|
Preventive Care Visit (for spouse)
|
1 visit ($0 covered under preventive care) |
$0 |
1 visit ($0 covered under preventive care) |
$0 |
|
Cost Summary (yearly total medical cost based on above scenario)
|
|
$5,722.40 |
|
$6,082.36 |
| Tax Savings Opportunity |
Flexible Spending Account |
Health Savings Account |
Scenario 3 (Lab draws during one visit)
Savannah is 40, married with a husband and two kids. Savannah’s husband, Jake, goes in to have a comprehensive lab and tissue pathology done during the same visit.
| |
PPO |
HDHP |
| |
Service Provided |
Cost Incurred |
Service Provided |
Cost Incurred |
PCP Visit ($180 total charges)
(Labs Ordered) |
1 visit (standard PCP copay per visit) |
+$20 |
1 visit (full visit cost until deductible is met) |
+$180 |
|
(Family Member: Spouse)
Comprehensive Lab Panel ($538 cost)
Tissue Pathology ($645 cost)
|
2 lab draws (standard lab copay per visits) * for both services since done during same visit |
+$50 |
1 comprehensive lab panel (full lab panel cost until deductible is met)
1 tissue pathology (full pathology cost until deductible is met) |
+$538
+$645 |
PCP Visit ($180 total charges)
(Lab Follow Up) |
1 visit (standard PCP copay per visit) |
+$20 |
1 visit (full visit cost until deductible is met) |
+$180 |
(Family Member: Dependents)
4 Trips to Convenient Care
($600- Total Charges) |
4 visits (standard convenient/ urgent care copay-$20) |
+$80 |
4 visits (standard convenient/ urgent care visit-$150) |
+$600 |
|
Less Company-Provided HSA Money
|
HSA not applicable with PPO Plan |
$0 |
Annual amount provided by Carle Health |
($250) |
| Annual Premiums |
$227.60 bi-weekly premium (x24 pay periods) |
+$5,462.40 |
$180.14 bi-weekly premium (x24 pay periods) |
+$4,323.36 |
| Preventive Care Visit (for child) |
1 visit ($0 covered under preventive care) |
$0 |
1 visit ($0 covered under preventive care) |
$0 |
|
Cost Summary (yearly total medical cost based on above scenario)
|
|
$5,632.40 |
|
$6,216.36 |
| Tax Savings Opportunity |
Flexible Spending Account |
Health Savings Account |
Scenario 4 (Outpatient advanced radiology diagnostics during one visit)
Misty is a 29-year-old who has incurred some health complications. Misty is on family coverage and is having an MRI scan done on her brain as well as a CT scan on her abdomen. Misty is doing these during the same visit.
| |
PPO |
HDHP |
| |
Service Provided |
Cost Incurred |
Service Provided |
Cost Incurred |
Specialist Visit ($360 total charges)
(Imaging Ordered) |
1 visit (standard specialist copay per visit) |
+$40 |
1 visit (full visit cost until deductible is met) |
+$360.00 |
|
MRI on Brain ($2,530 cost)
CT on Abdomen ($1,410 cost)
|
2 imaging services (standard radiology copay per visit)
* for both services since done during same visit |
+$250 |
1 imaging service (full radiology cost until deductible is met)
1 imaging service ((full radiology cost until deductible is met)
Deductible met at $4,000 for $300 (remaining cost x 20% coinsurance) |
+$2,530
+$1,110
+$60 |
Specialist Visit ($360 total charges)
(Imaging Follow Up) |
1 visit (standard specialist copay per visit) |
+$40 |
Deductible met on above service.
$360 (cost)x20% coinsurance |
+$72 |
| Less Company-Provided HSA Money |
HSA not applicable with PPO Plan |
$0 |
Annual amount provided by Carle Health |
($250) |
| Annual Premiums |
$227.60 bi-weekly premium (x24 pay periods) |
+$5,462.40 |
$180.14 bi-weekly premium (x24 pay periods) |
+$4,323.36 |
| Preventive Care Visit (for child) |
1 visit ($0 covered under preventive care) |
$0 |
1 visit ($0 covered under preventive care) |
$0 |
|
Cost Summary (yearly rotal medical cost based on above scenario)
|
|
$5,792.40 |
|
$8,205.36 |
| Tax Savings Opportunity |
Flexible Spending Account |
Health Savings Account |
Scenario 5 (Outpatient advanced radiology diagnostics)
Jacob is 40-year-old who was just in a car accident. Jacob is on employee-only coverage and has to have an MRI scan done on his brain as well as a CT scan on his abdomen. Jacob is having these done on separate visits.
| |
PPO |
HDHP |
| |
Service Provided |
Cost Incurred |
Service Provided |
Cost Incurred |
Specialist Visit ($360 total charges)
(Imaging Ordered) |
1 visit (standard specialist copay per visit) |
+$40 |
1 visit (full visit cost until deductible is met) |
+$360.00 |
MRI on Brain ($2,530 cost)
|
$250 copay 1 imaging service (standard radiology copay per visit) |
+$250 |
1 imaging service (full radiology cost until deductible is met)
Deductible met at $2,000 for $890 (remaining cost x 20% coinsurance) |
+ $1,640
+ $178 |
|
CT on Abdomen ($1,410 cost)
|
1 imaging service (standard radiology copay per visit) |
+$250 |
20% coinsurance |
+$282 |
Specialist Visit ($360 total charges)
(Imaging Follow Up) |
1 visit (standard specialist copay per visit) |
+$40 |
20% coinsurance |
+$72 |
| Less Company-Provided HSA Money |
HSA not applicable with PPO Plan |
$0 |
Annual amount provided by Carle Health |
($250) |
| Annual Premiums |
$76.08 bi-weekly premium (x24 pay periods) |
+$1,825.92 |
$50.97 bi-weekly premium (x24 pay periods) |
+$1,223.28 |
| Preventive Care Visit (for child) |
1 visit ($0 covered under preventive care) |
$0 |
1 visit ($0 covered under preventive care) |
$0 |
|
Cost Summary (yearly total medical cost based on above scenario)
|
|
$2,405.92 |
|
$3,505.28 |
| Tax Savings Opportunity |
Flexible Spending Account |
Health Savings Account |
Scenario 6 (New child)
Tyler is 32 years old and working full time. Tyler is married and in good health. Tyler’s spouse, who is also covered on Tyler’s plan, is expecting a baby this year.
| |
PPO |
HDHP |
| |
Service Provided |
Cost Incurred |
Service Provided |
Cost Incurred |
|
Family Member (Tyler)
4 Trips to Convenient Care
($600 total charges)
|
4 visits (standard convenient/ urgent care copay-$20) |
+$80 |
4 visits (standard convenient/ urgent care visit-$150) |
+$600 |
|
Family Member 2 (spouse)
Prenatal, Ultrasound, Delivery
($50,000 total charges)
|
$1,000 deductible + 20% of remaining costs until the $4,000 individual out-of-pocket max is met |
+$4,000 |
$4,000 deductible + 20% of remaining costs until the $11,000 family out-of-pocket max is met |
+$10,400 |
|
Family Member 3 (child)
Hospital and Newborn Care
($8,000 total charges)
|
+$1,000 deductible
+ $1,400 (20% of remaining charges) |
+$2,400 |
$0 family out-of-pocket max has been met |
$0
|
| Less Company- Provided HSA Money |
HSA not applicable with PPO Plan |
$0 |
Annual amount provided by Carle Health |
($250) |
| Annual Premiums |
$171.34 bi-weekly premium (x24 pay periods) |
+$4,112.16 |
$129.12 bi-weekly premium (x24 pay periods) |
+$3,098.88 |
| Annual Physical |
1 physical ($0 covered under preventive care) |
$0 |
1 physical ($0 covered under preventive care) |
$0 |
|
Cost Summary (yearly total medical cost based on above scenario)
|
|
$10,592.16 |
|
$13,848.88 |
| Tax Savings Opportunity |
Flexible Spending Account |
Health Savings Account |
Scenario 7 (Emergency Department visit)
Kelly is 28 years old, working full time and is in good health. Kelly had a minor accident over the weekend and needed to go to the Emergency Department for medical care, but was not admitted to the hospital. This is Kelly’s first visit to the Emergency Department this year.
| |
PPO |
HDHP |
| |
Service Provided |
Cost Incurred |
Service Provided |
Cost Incurred |
|
4 trips to Convenient Care
($600 total charges)
|
$20 copay X 4 visits = $80 copay |
+$80 |
4 visits (standard convenient/ urgent care visit-$150) |
+$600 |
|
Emergency Department Visit for Minor Injury with Stitches ($5,000 total charges)
|
$200 copay + $1,000 deductible + $760 (20% of remaining charges) |
+$1,960 |
$2,000 deductible + $720 (20% of remaining charges) |
+$2,120 |
|
Follow up with Primary Care Provider
($200 total charges)
|
$20 copay |
+$20 |
20% coinsurance |
+$40 |
| Less Company-Provided HSA Money |
HSA not applicable with PPO Plan |
$0 |
Annual amount provided by Carle Health |
($250) |
| Annual Premiums |
$76.08 bi-weekly premium (x24 pay periods) |
+$1,825.92 |
$50.97 bi-weekly premium (x24 pay periods) |
+$1,223.28 |
| Annual Physical |
1 physical ($0 covered under preventive care) |
$0 |
1 physical ($0 covered under preventive care) |
$0 |
|
Cost Summary (yearly total medical cost based on above scenario)
|
|
$3,885.92 |
|
$3,733.28 |
| Tax Savings Opportunity |
Flexible Spending Account |
Health Savings Account |