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WILDLY depends. And it is never simple.
If I break an arm, and I go to the hospital, and there's not much that's done aside from a cast, and some PT at the end, I pay $0.
Now, what does that mean?
We have had our insurance for a long time, and as we pay our monthly premiums, a little money goes into an account called an FSA. This pays some of the co-pay, deductibles, etc. in the background for us.
What happens if I get cancer and need to have some care for 7 years? Eventually that FSA runs out. Every insurance has a deductible that you pay before they start paying for everything. So we might have to pay $5k out of pocket annually and then insurance pays the rest.
What if I need to travel to another city to talk to a specialist? There might be airfare, hotels, food, etc. that we pay that is "part of the treatment" but not paid for by insurance.
What if I need medication? Might be $25 every trip to the pharmacy. Might be $300. Depends on the medication, how new it is, are there cheaper alternatives?
What if I get sick long enough where I lose my job? I might lose my insurance as well, and then have to apply for government assistance, that might make other medical bills different.
I assume you need to have health insurance? As in, you mention paying 0$ if you break your arm. But do you have to pay monthly premiums for it to be 0 at the hospital ?
And I have no idea but - presumably you would claim on the insurance for the broken arm, does that then impact your monthly premiums or coverage afterwards?
If you have insurance through your employer, then no the insurance company can’t raise your rates. And part of the reason for the Affordable Care Act (ACA, sometimes called Obamacare) was to make it so people who are getting the insurance themselves also can’t have their rates raised or get turned down for insurance because they have pre-existing conditions. However insurance companies can raise everyone’s rates when the insurance is up for renewal each year.
Most insurance plans have several different costs: 1. The monthly premium you pay to have insurance coverage. Some employers pay this themselves, otherwise it gets taken out of every pay check.
Co-pay: Usually a set amount ($30, for example) you pay to see a doctor for office appointments that aren’t an annual check-up*. So say I get an ear infection and see my primary doctor to get it treated, I’d pay the co-pay for that visit. Sometimes things like x-rays, blood work, CTs can be a set amount, other times it’s something like insurance will cover 65% of the cost. For some plans, co-pays are included when figuring out if you’ve reached your deductible.
Deductible: The amount you have to pay before “co-insurance” kicks in. Co-insurance being the percent of your bill insurance will pay (for us it’s 75% after we pay $3500 in a calendar year).
Out of pocket max: When you’ve spent this amount in a calendar year after that insurance covers 100%. Often plans have both individual and family maximums, with the family amount being higher.
Usually the more you pay in monthly premiums, the lower your deductible and out of pocket maximums will be. So each year people have to try and decide what they think their health bills will be next year when picking their plan (you can’t change plans mid-year unless something happens like changing job, getting married/divorced, having a kid). If you’re pretty healthy you might pick a lower monthly plan with higher out of pocket amounts because you don’t expect to have to pay much out of pocket. If you’re someone with a chronic condition or you’re expecting to need surgery or a costly treatment you might go with the higher monthly plan so you don’t have as high of out of pocket amounts.
For example, my spouse had to go to the ER a few years ago for what turned out to be a collapsed lung. They didn’t have to stay in the hospital overnight. I forget the total bill (or I’ve just blocked it from my memory), but our part ended up being about $5,000. Insurance kicked in after the bill got to $3,500, and they covered 75% of everything that was over $3,500. The most we would’ve paid was $6,000 (the individual out of pocket max), however we would still have to pay bills for myself and our kid up to $12,000 (family out of pocket max).
*Another part of the ACA was to make annual preventative screenings (like annual physical, mammogram for women over a certain age, prostate screening for men, etc) free.