Medical Insurance Enrollment questions
 

Alright it is that time of year again. The college I work at it changing insurance companies from Blue Cross Health Advantage to UMR that is using United Healthcare.
The new company is pushing the High Deductible Health Plan. I am now trying to figure out if it is worth it for me to switch from my PPO/FSA to the HDHP/HSA.
I am not sure how to figure out the costs that would be different. They cannot provide me information ahead of time as to the "discounts we will get at our PCP" over what paying full price would actually cost. They cannot provide me information as to what prescriptions that I take will actually cost with the southern scripts, mail order company, that we will be required to use.

Any advice would be greatly appreciated.
Hoping that there is a medical insurance agent/consultant on here!!!

Don't get sick and don't get hurt. Cancel insurance.

Can't live in dream world.

If you plan on having a lot of procedures this year pay the higher premium payment with a lower deductible. If you don’t plan on procedures go for the lower premium hospital advantage with a higher deductible and a reasonable out of pocket expense for the year.

You gotta crunch the numbers to see what works best for you this year

I don't plan on procedures but I do have 3 scripts a month. That I have no idea about what the cost will actually be with no real or standard script deductible.

If you go to your insurance website you can compare plans. RX/Doctors et al

Just have to research it nowadays

An HDHP is not a specific type of plan. If you were a PPO before, you’ll probably still be a PPO. As for your question, it’s kind of odd that they would ask you to sign up for a plan that you don’t know the details. I’m not even sure if that’s legal. They should have your pharmacy benefits information. I’d consider calling Southern Scripts.

Now we had an hour long meeting. They didn't know and could not tell us any of that type of information.
I am thinking about calling my Dr which is in network with this new company and finding out their side of the $$$ info. I also thought about calling this new script company as well as my current Pharmacist and getting any and all info from them that I can.

HDHP and POS are both PPO but you can only have an HSA with a HDHP.
Their responses were they didn't know each and ever Dr. charges and what the discount would be actually. Nor did they know the prices of every medicine and southern scripts discounts on each of those. Even though I could and was ready to give them a list.

They is a bit of a vague descriptor. Can't really expect the workplace HR lady to know any of that.

Not the case we had 2 reps from the Insurance Agency that this is all being outsourced through giving the presentation and answering questions for over 400 of us.

I think the main difference is that the HSA allows you to keep the money in your account year over year, whereas I believe FSAs you have to use during the plan year or the money goes away. I had a high deductible plan and an HSA for a while. If you are pretty healthy you aren’t going to spend much each year and save on premiums. You can put the deductible amount into the HSA and keep it in case you need it at some point.

If you are married or have kids then you probably aren’t going to save money with the high deductible plan compared to the lower deductible plan. At least that’s my experience as a married guy with kids. I have a plan with high premiums and low deductibles and everyone but myself uses it heavily.

Truth be told, I don’t have the faintest idea regarding the legalities involved in rolling out plans to an employee, I just design them and price them. I do know that I’ve never enrolled in a plan for which I didn’t know all of the details.

You are providing way too little information about the plans for anyone to help you whatsoever.

You should know the premiums, deductibles, and coinsurances/copays under the plans at the very least. Hard to compare the situations without that.

Normally every insurance company has a list of the prescription drugs and what tiers of the plan they fall under. Your HR lady isn't going to provide you that.

For all we know at this point is you could be comparing a 1200/2400 PPO 70% plan to a 1500/3000 HDHP 100% plan and so the benefits of the HDHP, especially if you contribute the deductible to the HSA, could far outweigh the PPO plan. We also have no idea how much you use the doctor and prescriptions you're on, which will factor into your choice. And, I doubt you'd want to divulge that information. You need to get more facts in order.

Yes and no. You are correct that the HSA allows you to keep or roll over the money that you don't spend year after year.
You can only get the HSA if you get the High Deductible Health Plan which is that they don't pay a dime until I spend $3000 out of pocket which is also the maximum out of pocket expense. But I can put $3550 in it a year and anything I don't spend I get to keep tax free.
If I ever get over $2K in the account that I don't feel I will need I can roll it into a money market and let it make me even more money.

A POS and a PPO are similar, but not the same. A PPO, POS, EPO, HMO can all be HDHP. All HDHP indicates is that it’s high deductible and can have an HSA. It doesn’t indicate anything about the network.

I guess all I was trying to say is that the high deductible plan can be beneficial if you aren’t going to need to spend a lot on medical costs and don’t get unlucky. The more typical lower deductible plan is better if you are a high consumer of medical services.

I doubt I’ve had more than $5k of medical services in the last 15 years. My wife and kids on the other hand...

If I was single I’d do the HDHP and take the risk. No way I would do that now.

Wish I could post a pic of their breakdown.
The POS plan which I can choose for $130 a month has a $1500 deductible with a $5000 maximum out of pocket. $35 copay at Dr. $45 at specialists. Copay plus 20% up to the $5K max. Scripts are $20, $50, $70 for Generics, Preferred, Non-Preferred. Wellness covered 100%.
The HDHP which I can choose for $75 a month has a $3000 deductible which is also the max out of pocket. Wellness is covered 100% everything else is 0% covered until deductible is met.

I am on Simvastatin, Spiriva Respimat and Albuterol Sulfate HFA. I see the Dr twice a year for blood work and a wellness checkup.


Hope that helps. Any other info that might help?

I would probably consult with your financial person instead of the ins company on which option would be better for you. But shot in the dark here from someone that has worked in the insurance field, you'll probably want to stick with the PPO.

I would double check those numbers.

It is in print on their color brochure that they gave over 400 of us today.

If you are generally healthy, go high deductible. The guvment is pushing this like 401K.

HDHP only makes sense if you are fairly healthy and actually plan to contribute to an HSA. An HSA has many benefits being tax free, rolling over from year-to-year all while providing you a place to put money for future healthcare costs. I think most healthy, single adults should be choosing a plan that allows them to contribute to an HSA.

If you end up needing a costly procedure, however, you'll be paying a large out of pocket sum for the year to meet the deductible. If you have a family, you increase the chances of having to meet that high deductible just in terms of sheer volume of services for 3 or more individuals, so many times having a HDHP makes less sense for a family.

I am using a HDHP and an HSA. It is the cheapest plan my company offers. My wife and I are very healthy and don't usually go to the Dr. for more than routine checkups. My company contributes "seed money" $2000 to the HSA account to help meet the deductible.

We max out our contributions and have never taken a dime from the HSA account. We treat it like savings. If we have something come up we just pay out of pocket and keep racking up the savings. It is by far the best deal for my wife and I. Our plan is to use that money to help fund medical expenses in our retirement years.

We have learned that if you hang on to all of your qualifying receipts or load them into the receipt vault with the HSA provider you can go back and make a claim (withdrawal) against that receipt at any time. They don't expire!

Oh ok. That's a little unusual which is why I asked.

Does the HDHP cover well being screenings at 100%? And what are the deductibles and MooP costs for the PPO and your age?

Those seem like pretty expensive generics. Before you let the company do your meds, check GoodRx and places like Walmart, Costco, and the like. I've never paid over $10 for any generic.

You should gather as much info as you can regarding the prescription coverage of the plans offered, specifically around your medications and possible eligible discounts.

I do a HDHP/HSA and take an expensive medication. When the script gets ordered, the total goes towards my deductible, but my plan offers a discount for the medication which only costs me $5 every time it's filled. So literally 2 fills maxes out my out-of-pocket maximum on paper, yet only costs me $10 actual. I keep my out-of-pocket max balance in my HSA just in case something happens between Jan 1 and the time my script maxes out my deductible (4 weeks) then I roll the rest into investments. Every year.

I've had this set up with 2 different carriers.

A little more info would still help, but overall health insurance and picking plans is a simple math equation. That said, it CAN be confusing when not familiar with the terms.

First question in your particular situation: Does your employer contribute anything to the HSA on your behalf for picking the HDHP? If they do, it's free money and may make that plan more enticing.

With the information provided, IMO, it still looks like I'd pick the HSA plan if I were you. There's a $55 monthly premium difference (or $660 annual premium difference) coming out of your paycheck. Add that $660 difference to the difference in deductible and you're looking at only $840 difference between plan 1 and plan 2 when simply comparing deductible amounts.

If you also take into account that the HDHP has 0% coinsurance, or in other words the deductible is the same as the max OOP (out of pocket), it becomes even more enticing. You could add whatever amount you want to the HSA out of your paycheck, tax-free mind you, as well to make up the potential difference in deductible levels.

Let's say you have a catastrophic event, or need a surgery, etc. In the $1500 deductible plan, you'll pay the first $1500 to satisfy the deductible and then also be responsible for 20% of the difference on everything above that number. Not many surgeries or health events are in that price range.

So....lets assume it's a $6000 hospital bill after network discounts. You pay the first $1500 and then you owe 20% of the remaining $4500, or another $900. So for that hospital visit, you owe a total of $2400 and insurance paid the other $3600. If you had the HDHP, you would pay the deductible, $3000, and then you're finished with any in network out of pocket expenses, so insurance is paying the other $3000.

Again that's a hypothetical number/cost for an event, but even in that situation, are you any better off with the lower deductible plan than the HDHP? At first glance, you might assume yes, because in one you're only paying $2400 and the other you're paying $3000. But remember you paid a higher premium for that plan, so in reality your out of pocket expense is slightly higher still when you include the extra $660 that lower deductible plan cost you already. Make sense??

Lot's of rambling there...I apologize if TLDR. I am a fan however of HDHP for those that can afford to fund an HSA, don't have a lot of health issues, etc. IMO, the vast majority of the public should be on HSA's. It makes you use the doctor smarter and honestly would reduce overall health care spending.

In regards to your prescription question, I would GUESS that the network on both plans are the exact same. Therefore, the allowed amount for all of your drugs and for any prescription should be identical. What will be different is whether you have different copay tiers between the two plans. Your simvistatin is cheap and generic, so you can probably get it at lower cost than even using your insurance. The Spiriva is likely the one you'll want to inquire about the most.

This answer won't help but it is just fun to say it!!

Switch to Obamacare:p

Can anyone tell me why the premium for myself and my daughter is the same as another associate and their 4 children?

Insurance premiums through employers are typically priced out as:

Employee

Employee + Spouse

Employee + Children

Family

I honestly don't know the reason. I can just tell you that is primarily how I seen plans priced. Doesn't matter if it's 1 kid or 5....they are all just "children" in the premium tier.

It's really rather silly when you think about it. I've had patients come in where their are 11 "children" on a working parents plan. Usually bc it's really good insurance, but they'll have like 3 biological, 4 step children and maybe some other loose connection.

From personal experience though, and it's the first time we've had insurance like this now that my wife has a new job, we pay different amounts based on number of kids. We only currently have one, but the cost is more when/if we have another.

there is no answer
a family appears to be 3 or more
but, if you have more children it will seem more fair:D

I'm an insurance broker and in the Med Supps and Med Advantage plans I always put my client in supps if they can afford it. I get paid exactly the same per policy regardless if it is a supp or Med Adv plan. Main difference is that a private company is going to take over all your Medicare benefits with med adv policies. Positives....for lower income people it's usually better than OG Medicare as they only pay roughly 80%. With Med Adv the biggest downside is they almost always have a network you must stay in and you have to get a referral from your PCP to do anything like getting any kind of imaging or need to see a specialist....some require one for the policyholder to wipe their ass...could be mistaken on that one, but you get the point. Out of network fees I've seen as low as 40% coverage. They tell you what pharmacy you have to go to as well as using their formularies or pay a higher copays elsewhere. Which means it's take it or leave it on each plan. Most Med Adv plans work like an HMO and don't cost you anymore than your part B monthly premium....usually. They are taken over by a private company. Now to the super shitty, they have copays for doctors and about everything you have done. They also have an annual out of pocket max of roughly $5300 to over $7k a year. Get really sick and a person living on $1200 a month from Social Security has an extremely tight budget and no plan for a catastrophic event. I personally think they are dogshit and will only recommend them if we can't get a better option for the client. The PPO plans aren't much better. They give you more freedom as in what doctors and facilities than can use. These plans also allow for much better coverage out of network so they travel better for people that aren't to ****in old to travel, but with that comes a higher premium. Most of the decent PPO plans are going to cost another $40 all the way up to $100 on top of your $134 Medicare premium...which is stupid. A lot of doctors and facilities don't accept a lot of Med Adv plans as their level of reimbursement is so shitty that they just refuse to deal with them. Humana is hit by that the most because they are so God damn cheap.

Now the smart way of doing it. If I have a client enrolling into Medicare part B for the first time as their primary insurance is they have 6 months before, the month of, and 6 months after that when they are in what's called Open Enrollment. Unlike private insurance for people under 65, they are allowed to deny coverage if someone can't pass through underwriting for a pre-existing condition. Beauty of Open Enrollment is the insurance companies can't ask you any questions about your health or medications. They have to take you even if you weigh 500 lbs with diabetes, a substance abuse issue, cancer, and still smoking like a chimney. Once OE is over though any time they want to make a change they have to go through underwriting. Being a broker I can usually find a carrier that I can get them approved through. Some are just ****ed though for things like being on an opioid medication, any chronic condition, stent placement in the last 2 years, pacemaker in the last 3, cancer in the last 5 years, etc. Diabetes is real bitch too as almost every carrier is different in what they allow. That is why it is imperative to get your client in the best possible med supp that fits their budget as it's more than likely going to be the last insurance policy they'll ever be able to buy if they have serious health issues.

I can't list a single negative thing about having OG Medicare as your primary and a med supp secondary....other than cost. Probably the simplest part that confuses policyholders the most until you pound it into their head as many times as necessary. If a medical provider accepts Medicare....they accept your supplement....period. Doesn't matter if it's a carrier they don't accept. The way this works is the provider bills Medicare and Medicare bills your Supplement for the rest. Another positive is guaranteed renewability as long as you pay your premiums. Could run up $2 million in one year in medical Bill's and they can't drop you or raise your rates. Rates are based on 3 factors.....age, gender, and geographic location...so another piece of mind plus.

Then travel is a big one. Medicare is accepted by 98% of providers across the country. So again if they accept Medicare....they accept your Supplement. Plans F, G, and N even cover you internationally for the first 60 days you are out of the US.

Other benefit is you are in complete control of your healthcare. No referrals, networks, wondering who accepts your coverage...all those things that suck about Med Adv.

Now the downside is obviously going to be higher premiums with supps as they pay for so much more. You will be paying probably $90-$150 more a month than if you have a Med Adv plan. I already told you that Med Adv plans have a minimum $5k out of pocket max, so if you can afford a supp it's a no brainers. The biggest reason is with all these copays and out of pocket you pay with Med Adv....you can't budget for your healthcare expenses as there are too many unknowns...and that's shitty because 80% of seniors have Social Security as their main or only source of income. If you're healthy that's great, but we all know father time is undefeated and will eventually gonna kick your ass, and have yet to see a old person get healthier as they age. You get sick at 70 and all of a sudden Med Adv sucks and you want to jump on the Supp program to stop the bleeding, but you ****ed yourself 5 years ago in OE and can't get through underwriting for a supp. Then things become really messy and frankly very sad when you have to tell them sorry.

Last part which is something that the government got right in developing a healthcare program is making each letter med supp plan standardized. The different plans are A, B, C, F, G, K, L, M, and N. They all suck except for F, G,and N.

If you have plan F you will never see a doctor bill and pay any out of pocket cost from a medical provider....of course that means plan F is going to be the most expensive.

The best plan is plan G. It's exactly the same as plan F other than you have to pay your part B yearly deductible which is only $185. Reason it's the best is over the course of the year plan F is about $400 a year more expensive than plan G. The only thing you get is you spent $400 to cover $185....which doesn't take a scholar to figure out you are paying $20 more a month with plan F over plan G for the exact same coverage. Stupid, but as a broker it's your job to give people all their options and steer them in the right direction that fits them and their budget the best. Plan N is a good option for some people to are extremely healthy and wanna save a few bucks. It's exactly like plan G other than when you go to the doctor or ER you will have copays. Up to $20 for your doctor and $50 for an ER visit. Easy way to help someone decide between G and N is ask them how many times a year they see their doctor. I would say there is about $200 a year difference between G and N. If you go to the doctor 7 times a year you take that times 20 to get the true savings. In that scenario they are only $5 a month...and if they end up sick and are having to go to the doctor a lot....plan N can become more expensive than plan G which you just explain it's $5 a month more for plan G, but they are much better protected for what is always an uncertain thing, especially with old folks.

I mentioned standardization earlier. What that means is that every plan letter plan offers the EXACT same coverage regardless of the carrier. So if plan G with Mutual of Omaha is the least expensive....pick that one. Again stupid to pay more for the exact same coverage. Some people are stupid and say "hey I've always had Blue Cross my whole life and never had an issue." Well good for them, but different players for different products. Blue Coss is one of the more expensive plans in the Med Supp market. You gotta just beat it into their heads that they are in a different market now and Blue Cross and a lot of other names people are familiar with suck in med supp.

Last thing....if you go supp over Med Adv, you will have to get a part D drug plan. Nationally they run between $16 to $35 a month. The advantage there is you get to choose the best plan for you and the medications you take, an option not offered when you go Med Adv.

In closing if you can afford to go the supp route absolutely a hands down no-brainer. With plan F and G a person can budget their healthcare cost to the dollar because no matter what they are covered at 100%. Certainty is the most priceless commodity you can offer someone. Unfortunately not everyone can afford a supp and have to go Med Adv. Can't budget that with copays and big out of pocket maximums. Just a mathematical certainty that at some point in your retirement years on your fixed income you are gonna get ****ed. Can't think of anything else in the med supp vs. Med Adv....or more appropriately private company takeover plans debate. Happy to answer any questions anyone has though. Doubtful, but possible I left something out...happens.

Yep, my options are Employee + Children. Adding my child to my plan is raising my premium $242 per month. Joe Employee adding his 5 kids to his plan raises his premium the same $242 per month. Seems to me like people in my situation are getting screwed over pretty good.

My company's PPO and HDHP have the same out of pocket max.

For family PPO it is 1000/7000
For family HDHP it is 3000/7000
They are both 80/20 after deductible with all preventive care covered 100%.

I save $2,000 per year going with HDHP, plus my company puts $500 into my HSA. I can't see any reason why I would ever go with the PPO.

I had an FSA a few years ago and switched it to a HSA last year. Big difference between them (at least with our plan) is that FSA funds are all available immediately, but you have to use it or you lose it. With the HSA, funds were available as they were deposited into the account. The nice thing is that funds carry over from the previous year.

i'm sure that this has been brought up in the thread or you are aware of this but just thought I'd share my experience.

Good luck!

FWIW an HSA is a great way to put money away that you can use later to help pay for insurance between the time you retire and are eligible for Medicare.

I'd research the cost of your meds under the HDHP and cost you'd pay for your normal visits. If you're paying 100% up until the deductible is met, you'll need to know this to make a good decision. You should do the math on both plans. What would be your normal cost under each plan for your meds, visits, and premiums on a monthly and annual basis? GoodRx is fairly cheap for Simvastatin, but I'm not sure on the asthma meds. If you're taking a cholesterol pill, that certainly means you may be at a higher risk for a catestrophic event so factor that in. Blake did a really good job of breaking down some of the math for you.

What you do know is that if you contributed $250 a month to your HSA, you'd pay the deductible over a year. The question is, would you exceed $250 a month in costs under that plan up until the deductible is met. If you don't, going with an HDHP/HSA plan makes sense because you can bank for the future. One thing to factor here too is your bank account. You know for a fact that 3900 is the max you'll pay during a year under this plan. Can you cover that now? You could pay $6560 under the other plan. If you have the funds for a catastrophic year, then the HDHP makes far more sense regardless.

The college is going to "front" the money into the HSA for every employee that decides to go that way. They are not matching or putting anything into that plan though.

I have called my doctor and pharmacy, which are both in network, to get costs and so I can submit them to the Insurance company so they can tell me the qualifying discounts on all. Now I am just waiting for the pharmacy to get back with me.

Steal some illegal immigrants identity and apply for EVERYTHING so you will be covered for FREE!

Man I hate the insurance game bullshit.
This new insurance sucks. It is United Healthcare by UMR. We had Blue Cross Health Advantage before. Both insurances had a $1500 deductible with a $5k out of pocket clause. What I have found out now after trying to use it is that the new insurance is that I have to pay out $1500 before they pay a dime. Then they will pay 80% up to the $5k where then they would pay 100%.
It turns out that the insurance is basically for a person to get a co-pay to see their PCP and to get a co-pay at the pharmacist. IMO that is not much insurance and seems damn expensive for $135 a month.
I can get better insurance for cheaper through TrumpCare. I am trying to get my employer to allow me a "life event" to get out of this crap insurance.

I’m somewhat confused as to what you thought it was going to be. I mean, that’s how deductibles work. Not trying to be a dick, but that’s just the way it works. Sounds like you actually have a decent plan. I’m this day and age, a $1500 deductible is pretty low.

The Blue Cross Health Advantage, the insurance we had in 2019, had the same deductible but they paid 80% on the way to the deductible not only paid after that deductible.
I had an x-ray a few months ago I had to pay $59 as my portion of that and it is the first imaging that I had had done under that policy.
Now, with United Healthcare through UMR new to us in 2020, I have to pay out $1500 before they will start to pay the 80% on the way to the maximum out of pocket of $5000.

Then what you had before was $1500 in coinsurance, not a deductible. Anytime you see the word deductible it means that's what you have to pay before the insurance company will pay anything.

Well now you know why they got rid of that old plan. Also I don't think you quite fully understand the plans.

Yeah, as mentioned by someone else, you had a $0 deductible plan previously which would be way more expensive than what you have now. Sounds like your employer used to pay a lot of the cost share and were tired of doing that. I think your gripe is with your employer rather than your insurer.

This.

Know what you signed up for and the terminology.

Our price went up from $118 a month to $135 a month for shittier insurance.

Oh I don't understand all the bullshit and they try to do that on purpose it seems. The agency and our administration told us all that we would not notice much of a difference. There have been complaints by over 50 of the employees about this insurance already.

Right, which is your price, not what the insurance costs. Your portion basically stayed the same while your employers portion of the cost share cake down significantly.

They told us all in the meetings that their cost also increased 25% with this new policy but it was significantly less than the increase to stay with Blue Cross Health Advantage plan that they had prior.

Well I don’t know what to tell you. Somewhere, something is breaking down, but without intimate knowledge of everything, I couldn’t begin to guess where.

Well, the repeal of the individual mandate penalty, for starters.....

It not like people weren't told this crap was going to happen.

UMR is a subsidiary of United HealthCare.

You can't get cheaper insurance through "TrumpCare." Well, you could get cheaper insurance, but the crap that is now allowed that is cheaper will ultimately cost you a *lot* more money as they, in actuality, don't cover anything.

Yeah, that has nothing to do with the current discussion.

Well, yeah, it actually does...when you allow those who are least likely to use the insurance to leave the risk pool, costs tend to go up for everyone else. Anthem and UHC aren't just going to rely on local employer based aggregates for individual actuarial analysis; they are looking at a national scale.

This was the first year that the individual mandate wasn't enforced, so the insurance companies were probably pretty aggressive in their cost structure and why you saw a premium increase of over 25% (at least for the employer) year over year. You can probably expect double digit increases year over year going forward.....

Not sure what shelter you've been able to hide under. That's been the trend in health insurance for 20 years.

There are several people I know that have that insurance, TrumpCare. One had a hernia surgery recently, total out of pocket was $800.

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I don't think you understand the difference between "Trumpcare" and the ACA (Obamacare). People who purchased their health insurance from the marketplace, like the people you mentioned, bought a plan that is regulated by the ACA. You can thank Obama for that. What had been traditionally known as "Trumpcare," the AHCA, did not pass the Senate. With the SC ruling that the individual mandate penalty not being enforceable, a bunch of psuedo-insurance "policies" became available in certain states; those "policies" have about as much value as a degree from tRump University.

For the record, I’m a health actuary at a major insurer (not United or one of the Blues), so I’m intimately familiar with how commercial insurance is priced.

Centene?

Haha, no, but I did interview with them about three years ago. They wanted someone with Medicare experience though and my history is in commercial. I’m not going to be specific about who I work for, but since I did say a major insurer, that pretty much leaves Cigna, Aetna, and Humana. It’s one of those three.