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 | $1,701.48 | $1,417.68 | $1,196.16 | $1,180.32 |
| 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 | $1,964.48 | $1,680.68 | $1,459.16 | $1,443.32 |
| Tax-advantaged account money | -$400 | -$400 | -$400 | -$400 |
| Total expenses | $1,564.48 | $1,280.68 | $1,059.16 | $1,043.32 |
| Choice HSA | Value HSA | Choice HRA | Value HRA | |
|---|---|---|---|---|
| Annual deductible | $2,500 | $4,300 | $5,000 | $6,550 |
| Annual paycheck contributions | $1,701.48 | $1,417.68 | $1,196.16 | $1,180.32 |
| 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 | $2,787.48 | $2,503.68 | $2,282.16 | $2,266.32 |
| Tax-advantaged account money | -$400 | -$400 | -$400 | -$400 |
| Total expenses | $2,387.48 | $2,103.68 | $1,882.16 | $1,866.32 |
| Choice HSA | Value HSA | Choice HRA | Value HRA | |
|---|---|---|---|---|
| Annual deductible | $5,000 | $8,600 | $10,000 | $13,100 |
| Annual paycheck contributions | $5,700.96 | $5,076.60 | $4,589.28 | $4,554.60 |
| 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 | $10,486.96 | $9,888.60 | $9,401.28 | $9,366.60 |
| Tax-advantaged account money | -$550 | -$550 | -$550 | -$550 |
| Total expenses | $9,936.96 | $9,338.60 | $8,851.28 | $8,816.60 |
| Choice HSA | Value HSA | Choice HRA | Value HRA | |
|---|---|---|---|---|
| Annual deductible | $5,000 | $8,600 | $10,000 | $13,100 |
| Annual paycheck contributions | $7,824.12 | $6,972.84 | $6,308.40 | $6,260.88 |
| 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 | $9,249.12 | $8,397.84 | $7,733.40 | $7,685.88 |
| Tax-advantaged account money | -$950 | -$950 | -$950 | -$950 |
| Total expenses | $8,299.12 | $7,447.84 | $6,783.40 | $6,735.88 |
Team Member Benefits
Learn more about the benefits available to eligible Team Members. Select the benefits category that matches your position.
