Getting a medical procedure preapproved by a health insurer might sound like a confirmation that the bill is covered. But as one Washington woman discovered, an insurer can approve a procedure and still leave the patient responsible for nearly the entire bill.
Stephanie Halver of Vancouver, Washington, was considered at high risk of developing breast cancer because of her family history and dense breast tissue. Her doctor recommended an annual breast MRI six months after her yearly mammogram because MRIs can detect abnormalities that mammograms may miss. Her insurer preapproved the MRI, and her September scan found nothing concerning.
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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.
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.
Deductibles can also leave people with employer-sponsored insurance responsible for substantial costs before their plans begin picking up more of the tab. In 2024, workers with single coverage and a general annual deductible faced an average deductible of $1,787, according to KFF data.
Having health insurance doesn’t necessarily protect Americans from falling into debt, either. Americans collectively owe at least $220 billion in medical debt.
And while the uninsured are more likely to carry healthcare debt, having coverage is no guarantee against it. Among adults under 65, 62% without insurance reported healthcare debt in 2024, compared with 44% with insurance.
With healthcare debt affecting Americans regardless of insurance status, the issue has repeatedly drawn attention in Congress.
The Senate Committee on Health, Education, Labor and Pensions has held hearings on healthcare affordability in recent years, including multiple hearings since 2025. Proposals discussed have included greater price transparency, changes to insurance plans and reforms to federal health programs.
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This article originally appeared on Moneywise.com under the title: A $1,205 MRI was preapproved by insurance. The patient was still on the hook for almost all of it
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