Medical Claims Examples
These examples can help you find the right Bloomin’ Brands medical plan.
Choosing the right plan
The illustrative claim examples below can help you get a feel for the impact of paycheck contributions and your share of typical out-of-pocket expenses for the various plan options.
| Choice HSA | Value HSA | Choice HRA | Value HRA | |
|---|---|---|---|---|
| Annual deductible | $2,500 | $4,300 | $5,000 | $6,550 |
| Annual paycheck contributions | $1,616.42 | $1,346.80 | $1,136.46 | $1,121.38 |
| 1 preventive office visit | $0 | $0 | $0 | $0 |
| 1 primary care doctor visit | $208 | $208 | $208 | $208 |
| 1 teladoc visit | $55 | $55 | $55 | $55 |
| Subtotal | $1,879.42 | $1,609.80 | $1,399.46 | $1,384.38 |
| Tax-advantaged account money | -$400 | -$400 | -$400 | -$400 |
| Total expenses | $1,479.42 | $1,209.80 | $999.46 | $984.38 |
| Choice HSA | Value HSA | Choice HRA | Value HRA | |
|---|---|---|---|---|
| Annual deductible | $2,500 | $4,300 | $5,000 | $6,550 |
| Annual paycheck contributions | $1,616.42 | $1,346.80 | $1,136.46 | $1,121.38 |
| 1 preventive office visit | $0 | $0 | $0 | $0 |
| 2 primary care doctor visits | $416 | $416 | $416 | $416 |
| 2 teladoc visits | $110 | $110 | $110 | $110 |
| 1 outpatient surgery | $560 | $560 | $560 | $560 |
| Subtotal | $2,702.42 | $2,432.80 | $2,222.46 | $2,207.38 |
| Tax-advantaged account money | -$400 | -$400 | -$400 | -$400 |
| Total expenses | $2,302.42 | $2,032.80 | $1,822.46 | $1,807.38 |
| Choice HSA | Value HSA | Choice HRA | Value HRA | |
|---|---|---|---|---|
| Annual deductible | $5,000 | $8,600 | $10,000 | $13,100 |
| Annual paycheck contributions | $5,415.80 | $4,822.74 | $4,359.94 | $4,326.92 |
| 2 preventive office visits | $0 | $0 | $0 | $0 |
| 5 primary care doctor visits | $1,040 | $1,040 | $1,040 | $1,040 |
| 2 teladoc visits | $110 | $110 | $110 | $110 |
| 1 outpatient surgery | $560 | $560 | $560 | $560 |
| 1 emergency room visit | $3,076 | $3,102 | $3,102 | $3,102 |
| Subtotal | $10,201.80 | $9,634.74 | $9,171.94 | $9,138.92 |
| Tax-advantaged account money | -$550 | -$550 | -$550 | -$550 |
| Total expenses | $9,651.80 | $9,084.74 | $8,621.94 | $8,588.92 |
| Choice HSA | Value HSA | Choice HRA | Value HRA | |
|---|---|---|---|---|
| Annual deductible | $5,000 | $8,600 | $10,000 | $13,100 |
| Annual paycheck contributions | $7,432.88 | $6,624.28 | $5,993 | $5,947.76 |
| 4 preventive office visits | $0 | $0 | $0 | $0 |
| 5 primary care doctor visits | $1,040 | $1,040 | $1,040 | $1,040 |
| 5 teladoc visits | $385 | $385 | $385 | $385 |
| Subtotal | $8,857.88 | $8,049.28 | $7,418 | $7,372.76 |
| Tax-advantaged account money | -$950 | -$950 | -$950 | -$950 |
| Total expenses | $7,907.88 | $7,099.28 | $6,468 | $6,422.76 |
Team Member Benefits
Learn more about the benefits available to eligible Team Members. Select the benefits category that matches your position.
