HSA vs. a PPO

[raeoflyte]

I have quotes for a PPO plan and am trying to compare it to my current HSA.  Premiums are $500-800 a month higher on the PPO.  Deductible is comparable on the lower end of the monthly PPO plan, and out of pocket max is about $2k higher on the PPO.  

When I'm comparing the PPO the way I expect an HSA to work, the PPO would cost me a heck of a lot more.  But how can I tell if the PPO would cover specialist appointments on a copay?  That would certainly make a difference.  I think it would cover prescriptions on a copay basis too--right?  If both of those are true, when does the deductible kick in outside of ER visits?  

I spoke with the benefits administrator for the PPO, but they said that I couldn't get information from the insurance company directly unless I'm on the plan.  Which definitely makes it harder to figure out. 

For anyone who doesn't know, ds7 has type 1 diabetes which means big medical bills.  From what I can tell on the PPO plan, they won't cover one of the devices that ds uses that would cost $5400 without coverage.  We would have the doctors office appeal that if we change and hopefully due to his age it would be approved.  We couldn't know the outcome on that before making the switch though.  

[Anne_in_VA]

Is this for private insurance plans or through your job?  If through your job, tHat  sounds like your plan administrator doesn't understand the plans fully.  They should be able to tell you what is covered and what isn't.  If it's private insurance, then the benefits admin should know, but if you're going through an agent, ask them.

[raeoflyte]

I have a job offer, so I'm comparing my current insurance to the new companies. I don't have any documents though.

[quince]

I don't think there is a way to tell what the plan is applying the deductible to without seeing the docs.

When we were on a PPO plan, deductible kicked in on non preventative care visits, including specialist visits.

I know some of them exclude the first 3 sick visits from deductible, some exclude Rx, but I think it is pretty mix and match.

[raeoflyte]

Aug 15, 2016 20:25:48 GMT -5 quince said:

I don't think there is a way to tell what the plan is applying the deductible to without seeing the docs.

When we were on a PPO plan, deductible kicked in on non preventative care visits, including specialist visits.

I know some of them exclude the first 3 sick visits from deductible, some exclude Rx, but I think it is pretty mix and match.

That kind of plan would make this insurance crazy expensive, unless they considered his specialist appointments preventative care.  

I'll ask for the docs tomorrow.  

[Anne_in_VA]

Since you have significant medical expenses I'd ask HR are the company making the job offer.  IIRC most PPO's require a copay for specialist appointments, although depending on the policy, some plans require a co-insurance payment.  Co-insurance means you pay a %of the cost rather than a set $ as the co-pay.  My insurance has a copay for regular doctor visits plus a copay for scripts, however there is a co-insurance for specialists, hospitals admissions and some procedures.  For example, I had cataract surgery earlier this year and had to pay a co-insurance for both the doctor, anesthetist and the surgery.  IIRC my cost was about 20% of all fees.

This is really highly dependent on the policy though, so you'll need to check with the new company further before deciding as co-insurance and copayments can get expensive fast if you have a lot of specialist appointments and Meds.

[The Walk of the Penguin Mich]

My PPO covered all my specialist bills like they did everything else.  I had a (larger) copay for those appointments than my PCP (I want to say $45 vs $25), but once I hit my deductible and max OOP cost, everything was covered.

[raeoflyte]

Aug 15, 2016 20:45:23 GMT -5 The Walk of the Penguin Mich said:

My PPO covered all my specialist bills like they did everything else.  I had a (larger) copay for those appointments than my PCP (I want to say $45 vs $25), but once I hit my deductible and max OOP cost, everything was covered.

This is kind of what I'm afraid of.  If we are likely to hit the deductible/OOP on the PPO (which we always do on the HSA) the total cost of the coverage would be at least 11k more a year for what the plan covers.  

[Cookies Galore]

My employer provides Personal Choice PPO coverage. Copay is $15 for primary care doctor and specialists, and $25 for ER (waived if admitted). No deductible ($250 out of network deductible) and out-of-pocket max of $1000. I love my coverage. It's been over seven years, but I'm pretty sure I was given some sort of plan info during my interview. How the hell else can you make a decision about an offer without benefit info?

[The Walk of the Penguin Mich]

Aug 15, 2016 20:53:09 GMT -5 raeoflyte said:

Aug 15, 2016 20:45:23 GMT -5 The Walk of the Penguin Mich said:

My PPO covered all my specialist bills like they did everything else.  I had a (larger) copay for those appointments than my PCP (I want to say $45 vs $25), but once I hit my deductible and max OOP cost, everything was covered.

This is kind of what I'm afraid of.  If we are likely to hit the deductible/OOP on the PPO (which we always do on the HSA) the total cost of the coverage would be at least 11k more a year for what the plan covers.  

Then it depends on how much more the PPO covers vs the HSA.  How does the HSA cover specialists?  Is there OON coverage?  

[raeoflyte]

Aug 15, 2016 23:23:34 GMT -5 The Walk of the Penguin Mich said:

Aug 15, 2016 20:53:09 GMT -5 raeoflyte said:

This is kind of what I'm afraid of.  If we are likely to hit the deductible/OOP on the PPO (which we always do on the HSA) the total cost of the coverage would be at least 11k more a year for what the plan covers.  

Then it depends on how much more the PPO covers vs the HSA.  How does the HSA cover specialists?  Is there OON coverage?  

So far we've never needed an out of network specialist, but on the HSA the out of pocket max is the same for us in or out of network.  So we pick up everything to the deductible, then 20% until we hit the OOP max and then everything is covered.  

[saveinla]

There are various kinds of PPO plans - the most common one would be the 80-20 plan where you will need to pay 20% of all costs until the deductible is met. After that everything will be covered 100%. But check with them since not all plans are structured the same.

The best plan that we had was one that covered everything with just a copay for the doctor visits and pharmacy. 

As PP have said your plan admin should know what will be covered. If not, ask the HR department for more details - they should have all the information for you to decide.

[raeoflyte]

They're supposed to be sending me over a summary of the plan, but the HR rep said that specialists would be covered by a $50 copay. She said yesterday anything the doctor orders at a visit is covered under a copay except for outpatient procedures, ER/hospital stays. I really need to see the paperwork (which for whatever reason seems to be an unusual request), but I'm definitely nervous that the insurance could just be too expensive. 

[Sam_2.0]

I've priced out our options every year, and even with the higher deductible the HSA always comes out to be the best deal even if we max out the insurance. I miss the good old days of the co-pay plans, lol.

[bean29]

Raeoflyte,

Can you chose between a HSA and a PPO at the new company, or are you comparing ins at your current job to ins at the new job?

At my company, we can choose between a HSA and a PPO. Corporate attorney says the HSA is a better deal - company pays lower premiums and if you are going to hit your deductible, the OOP maximum is lower. with the PPO once you hit your deductible, you still have copays to a certain point - so yeah, you might be understanding the policy correctly.

I think it is unusual for employees to require the info before accepting a job b/c companies want to hire employees who will not drive up their utilization which will result in higher future premiums. I was pretty much asked in my interview if I was married and if my husband carried the insurance. I tired to avoid answering the question directly. They made an offer to you and you need the info in order to determine if you will accept or negotiate for more $$. Collect the info you need before you accept the job.

[alabamagal]

Aug 16, 2016 10:19:59 GMT -5 Sam_2.0 said:

I've priced out our options every year, and even with the higher deductible the HSA always comes out to be the best deal even if we max out the insurance. I miss the good old days of the co-pay plans, lol.

HSAs are usually a better deal, but it doesn't work out for us.  DH has type 2 diabetes so he has frequent doctor visits for monitoring and testing.  And he takes a lot of meds.  The HSA plan we had covered a lot of "maintenance meds" but not his, so we would have had to pay full price ($800 or so a month) until we met OOP max.  So because of the meds and office visits and tests we are much better off with the copays and paying 10% for lab test (reminding myself I have a 3 lab bills to pay that are under $10 each). 

For the OP, I would just figure on a "worst case" cost for the new job to help make the decision.

[raeoflyte]

Well, still no plan summary but hopefully in the morning. I got online to double check our expenses this year, and the CGM that I thought was $5400 a year without insurance is actually almost $17k without insurance...

Worst case scenario on the new plan would be $26k more per year than what I have at my current job. (And to answer a question earlier--I'm comparing my HSA at my current employer, and the PPO plan at a company I *kind of* have a job offer at. That employer only has the PPO plan). I reached out to the hiring manager, told him that the #'s are a bit staggering right now considering the potential issue with the CGM. He was very supportive and said we'd look at comp once I know what it is all coming in at which tells me they want me and will work with me.

But we'll have to see. It's a sales job, so I could potentially make that kind of an increase, BUT if I'm having to bring in that much more before I start to net more I just don't know if I can go through with changing jobs. I realize insurance can change at any time and my company could switch plans every year putting me on a similar plan and we'd have to figure it out, and if I was unemployed or hated what I did I'd of course do it. My job right now has a lot of good things with it, and the fact that we've had almost zero insurance issues since ds dx that I'm not anxious to go someplace that I have to fight from the start.