Case Study: Navigating a Cancer Scare on a High Deductible Health Plan

Meet Marcus. He’s 52 years old and in decent health. He rarely used his insurance beyond the usual annual checks. Until one day, he suddenly needs it.

Self-Employed and in a Medical Crisis

Marcus is a 52-year-old freelance graphic designer. He’s healthy overall, exercises regularly, and only visits the doctor for annual checkups. Because he doesn't expect many medical expenses, he chose a High Deductible Health Plan (HDHP) with a lower monthly premium and a $6,000 individual deductible. His plan includes a Health Savings Account (HSA), which he contributes to when he can.

Then something changes. He starts having pain and frequent urination. His primary care provider refers him to a urologist for further examination.

Step 1: The Specialist Visit

Cost: $280 (negotiated rate)

Plan covers: $0 until deductible is met

Marcus pays: $280 out of pocket

On an HDHP, you typically pay the full cost of most services and this is applied toward the deductible before the plan begins to share costs.

Step 2: Imaging and Lab Tests

The urologist orders a CT scan and a urine cytology test.

CT scan cost (negotiated rate): $1,300

Lab test cost: $220

Marcus pays: $1,520

Out-of-pocket total: $1,800

Step 3: Outpatient Cystoscopy Procedure

Next, Marcus undergoes a cystoscopy (a procedure using a scope to look inside the bladder).

Facility + physician cost (negotiated rate): $2,000

Marcus pays: $2,000

Out-of-pocket total: $3,800

Step 4: Biopsy and Pathology

The urologist spots a suspicious area and performs a biopsy. The sample is sent to a lab.

Biopsy procedure cost: $1,400

Pathology lab cost: $400

Marcus pays: $1,800

Out-of-pocket total: $5,600

Step 5: Prescription Medications

After the biopsy, Marcus experiences inflammation and receives a prescription for antibiotics and pain medication.

Generic antibiotic: $18

Pain medication: $10

Marcus pays (retail price, but discounted under plan): $28

Running total: $5,628

Step 6: Insurance Kicks In

Marcus goes back for a follow-up test, and $372 later, he meets his $6,000 deductible. At this point, coinsurance begins. His plan will now pays 80% of his expenses for the rest of the calendar year, and Marcus will pay 20% until he hits his $8,000 out-of-pocket annual maximum.

Running total: $6,000

Step 7: The Diagnosis

Unfortunately, Marcus’s biopsy confirms early-stage bladder cancer. Fortunately, it is caught early and is a highly treatable form of cancer. His doctors recommends surgery to remove the tumor, followed by a short course of radiation therapy to reduce the risk of recurrence.

Step 8: Treatment

As a reminder, because Marcus met his $6,000 deductible, he is in the coinsurance phase of his High Deductible Health Plan. So his plan covers 80% of eligible medical costs, and Marcus pays 20% until he reaches his annual out-of-pocket maximum of $8,000. Here's a breakdown of the typical negotiated costs and what Marcus pays under his HDHP:

Service	Total Cost	Marcus Pays (20%)
Outpatient bladder surgery	$12,000	$2,400 (but only $2000 because then he hits his annual max of $8000)
Anesthesia and facility fees	$3,000	$0
Radiation therapy (6 sessions)	$8,000	$0
Follow-up specialist visits & labs	$2,000	$0
Total	$25,000	$2,000

GRAND TOTAL: $8,000

Since Marcus pays another $2,000 in coinsurance, he hits his $8,000 out-of-pocket maximum. From that point on, his plan covers 100% of covered care through the end of the plan year.

Total Cost Comparison

Let’s look at the bigger picture:

Total Marcus paid out of pocket: $8,000 (maximum allowed under his plan)
Total billed amount for all care and treatment: About $33,000

A Happy (and Cautiously Optimistic) Ending

Marcus is now cancer-free, recovering well, and back to walking his dog in the mornings. He’s grateful for early detection, good doctors, and supportive friends.

He’s not thrilled to have spent an unexpected $8,000 in a year, and this puts a strain on his finances for a little while, but he understands it could have been much worse. His HDHP protected him from financial devastation — but it did require him to pay a lot up front, and quickly. He also knows he’s lucky that he had this medical crisis earlier in the year. Had it all started in November or December, his annual deductible and out-of-pocket maximum would have reset on January 1, causing him to essentially double his expenses.

Would a Different Plan Have Been Better?

It’s a fair question, and one Marcus is asking as open enrollment approaches.

A High Deductible Health Plan works well when you're healthy and rarely need care, but it can feel financially painful when something serious happens. Marcus wonders now if a lower-deductible plan with a higher monthly premium might make budgeting easier, even if the total annual cost ends up being similar.

For example:

A Gold plan or PPO with copays could have allowed him to pay smaller amounts more gradually (e.g., $50 for specialist visits, fixed amounts for tests or procedures).
Some plans also offer cancer-specific riders or critical illness coverage to provide a lump-sum payout upon diagnosis, which could have helped offset non-medical costs like time off work or travel for care.

Final Thoughts

Marcus’s story is a powerful reminder that:

Understanding how your plan works before you need it is key
Hitting your max out-of-pocket can be painful, but it beats the alternative in a worst-case-scenario
There’s no one-size-fits-all plan — the “right” plan depends on your health needs, budget, and risk tolerance

If your situation changes, your health evolves, or you're worried about what a future diagnosis could bring, it may be time to review your coverage and explore whether another plan type might offer more peace of mind.

We’re here to help talk you through your options.

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