Then the bill arrived: Halver was responsible for $1,191.10 of the $1,205 MRI charge, after her insurer paid just $13.90. She was also charged $65.60 for medication, roughly half of which insurance covered.
Halver was relieved the MRI found nothing, but the bill left her confused.
“I’ve had many phone calls trying to understand” the charges, Halver told KFF News.
The bill stemmed from the coverage rules under Halver’s employer-sponsored health plan. Although the procedure was authorized, it wasn’t considered preventive care that had to be covered at no cost to her. As a result, the cost of the MRI was applied to her deductible, leaving her to pick up most of the bill.
Halver’s experience exposes another complication for Americans with workplace health insurance: The consumer protections in their states may not necessarily apply to their plans.
The “self-insured” employer plan loophole
The wrinkle for Halver and millions of Americans with employer-sponsored coverage is that some workplace health plans are “self-insured.” The federal government, rather than state lawmakers, regulates these plans, so state insurance mandates may not apply.
That can leave workers without protections their states have enacted for other health plans. In Washington, for example, state law requires many insurers to cover breast MRIs, but those protections generally don’t extend to self-insured employer plans like Halver’s.
“Sadly, these state-by-state laws” don’t “fix the federal problem,” according to Cathy Peters, an executive with the American Cancer Society Cancer Action Network.
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The rising cost of health care
While Halver’s case highlights an unusual disconnect between insurance approval and coverage, a $1,200 medical bill isn’t necessarily out of the ordinary.
U.S. health care spending has more than tripled from about $1.4 trillion in 2000 to nearly $5.3 trillion in 2024, according to the Peterson-KFF Health System Tracker, a project that monitors trends in the U.S. health system. In 2024 alone, Americans’ out-of-pocket health spending averaged $1,632 per person, not including what they paid in health insurance premiums.
