Author Topic: Advice/Reinforcement Needed On Unique Medical Plan Situation  (Read 432 times)

dcozad999

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Advice/Reinforcement Needed On Unique Medical Plan Situation
« on: November 08, 2019, 09:38:45 AM »
I need some help deciding on a medical plan this year, as my family has a unique situation. My wife has a chronic condition that requires a very expensive medication ($4554.12 per month) which is subsidized by the pharmaceutical company. Iím not exactly sure on the specifics as my wife sets it all up, but we only pay $5/month for the medication.

The thing that really works out in our favor, is that even though it is subsidized, the entire $4,554.12 gets applied to the deductible an out of pocket maximum. The first year I thought this was an error on the pharmaceutical companyís part, but after discussing with people here in the past, it apparently is legitimate since the full price was paid by somebody.

I have always done the Premium HSA plan before. I guess I took one look at the deductibles and OOPs on the others and got scared. But I actually decided to run the numbers this year and am now kicking myself, because it looks like, based on our situation, Iíve been going about this the wrong way all along.

A breakdown of the numbers is in the attachment.

I would save either $1,427 (Select) or $3,291 (Basic) on the premiums alone by taking the Select or Basic plan. The company does not contribute to the HSA in any of these plans. There is a Premium Plus plan which is identical to the Premium pan, however they deposit $1,200 into your HSA in January.  The premium is $1,200 higher, so over the year it all equals out.

Assuming nothing catastrophic happens prior to the January date of purchase, it appears to be a no brainer to go with the Select plan over the Premium plan. The savings on the premium more than makes up for the difference in remaining out of pocket. The remaining OOP between the Select and Basic, however, is massive at $4,850.

Assuming nothing catastrophic happens prior to the February date of purchase, the difference between the remaining OOP between the Select and Basic is $1,948, just slightly more than the $1,864 difference in premiums. Almost at break even.

Where the Basic plan really becomes favorable is after the March date of purchase. At that time, the savings in premiums between the two would overtake the difference in remaining OOP.

I guess I just need to decide how much risk I want to take on. Logic would say there is a very, very small chance of anything catastrophic happening (ie. $130,000 emergency) at all in the next year, let alone in the first month or two. So in my mind, I should take on a little risk and go with the Basic plan. But I have lifelong anxiety issues.  My anxiety wants me to keep the Premium plan. My mind has overcome that, and I am at least convinced enough now to switch to the Select plan.

I now need your help to convince me to go with the Basic plan. Or opinions on why you would go with the Select or Premium plan. These are the kind of decisions that always seem to paralyze me. If Iíve made any mistakes in the numbers, or just missed something completely, feel free to point it out.

Thanks in advance for your help.

hops

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Re: Advice/Reinforcement Needed On Unique Medical Plan Situation
« Reply #1 on: November 08, 2019, 09:54:36 AM »
If your wife's on a biologic, you're probably already aware that insurers are increasingly changing the rules because they don't want copay assistance covering deductibles. What flies with one company won't necessarily work with another, or even with the same company year after year. Have you verified that everything would remain the same under your 2020 plan? If not, it shouldn't be much of a hassle for her to verify with the copay assistance folks.
« Last Edit: November 08, 2019, 09:58:14 AM by hops »

BECABECA

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Re: Advice/Reinforcement Needed On Unique Medical Plan Situation
« Reply #2 on: November 08, 2019, 09:55:31 AM »
One thing that changes the equation is the after deductible cost. From your spreadsheet it looks like the other plans require you to pay more of a percent of the incurred expenses than your current plan? That skews it enough that I wouldnít consider the basic plan, since it looks like youíd be on the hook for 40% of costs instead of 10%. For the mid tier plan, since itís 20% instead of 10%, I might still stick with your current plan. It would require a lot more analysis of my past health history and how much 10% more would be on some likely scenarios.

dcozad999

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Re: Advice/Reinforcement Needed On Unique Medical Plan Situation
« Reply #3 on: November 08, 2019, 10:09:50 AM »
If your wife's on a biologic, you're probably already aware that insurers are increasingly changing the rules because they don't want copay assistance covering deductibles. What flies with one company won't necessarily work with another, or even with the same company year after year. Have you verified that everything would remain the same under your 2020 plan? If not, it shouldn't be much of a hassle for her to verify everything with the copay assistance folks.

The pharmaceutical stuff goes through Prime Therapeutics, who then passes the information to the insurance company. I don't know how that exchange works. They are still being used in our 2020 plan. This has been going on for the six years that we have had a plan with an HSA. I suppose you could be correct and that at some point they change it to not apply the subsidized portion to the deductible. Even then, we would still be paying only $5/month for the medication. Assuming we met the deductible on the Select Plan we'd be out an extra $1,000 over the Premium plan after the difference in premiums (5,400 Select deductible - 3,000 Premium deductible - 1,427 diff in premiums).