HDHP questions about deductible and in network payments

[FiguringItOut]

I have HDHP with with $1,500/$3,500 deductible.  What does that mean in terms of individual meeting their personal deductible before family deductible is met? 
If my daughter uses up her $1,500 deductible but family deductible is not yet met, will coinsurance kick in for her or will her charges continue at full in network cost until all $3,500 is met?  My daughter and I both will meet our personal $1,500 deductibles by mid April.  Another $500 before the coinsurance kicks in a not that big a deal in a grand scheme of things, but I want to understand how this work.  Insurance customer service was vague and less than helpful as usual.

Also, I started seen a doc where I will be having recurring appointments for a while.  She said that my in network charge is $95 until the deductible is met, then it is 20% coinsurance.   That's what I paid her for the last two appointments.  Now, I see that she submitted claims to the insurance and on insurance site it says that my payment should be $210, not $95.  Does that mean that this doc just accepts a $95 payment or will I have to pay additional cost to bring it up to $210?  Should I question her or just let it be?

And one last question slightly irrelevant.  This doc I see had me sign a 24 hour cancellation policy or I will be responsible for the payment.  I canceled this week's Tuesday noon appointment at 11pm Monday night because I came down with a really bad cold with fever and was to sick to get out of bed.  I did say in my email that I came down with fever and such and will not make the appointment.  Should I expect to pay the $95?  I know the 24 hr cancellation is standard, but I've never had to pay it before even when canceling last minute.  But this is a new doc and she seems somewhat a stickler to details.  If she insists, should I argue that this was not a planned or predictable event?  Or should I just suck it up and pay?





 

[StetsTerhune]

The deductible thing is actually specific plan dependent, so you'll need to ask your HR or insurance company this question to be sure  (and good luck with that).

In my experience, the vast majority of plans work as -- individuals can only pay up to individual deductible, but if the family deducible is already met by the total of other family members then an individual may pay less than the individual deductible.

So in your case you'd pay 1500 and then start paying coinsurance, then your daughter would pay 1500 and start paying coinsurance, but if there is a 3rd family member, they'd then pay 500 and then start paying coinsurance.

I can't be 100% sure that this is how it works in your case, but 90% sure.

[FiguringItOut]

The deductible thing is actually specific plan dependent, so you'll need to ask your HR or insurance company this question to be sure  (and good luck with that).

In my experience, the vast majority of plans work as -- individuals can only pay up to individual deductible, but if the family deducible is already met by the total of other family members then an individual may pay less than the individual deductible.

So in your case you'd pay 1500 and then start paying coinsurance, then your daughter would pay 1500 and start paying coinsurance, but if there is a 3rd family member, they'd then pay 500 and then start paying coinsurance.

I can't be 100% sure that this is how it works in your case, but 90% sure.

Thank you. This is what I originally thought, but then I called insurance and got all confused again.  Will call them again and hopefully get a different rep to explain it. 

[HPstache]

Our insurance company uses the word "true" vs. "embedded" to describe what you are referring to.  In our case at work, the deductible is "true family" but the OOP Max is "embedded".  A "true family" deductible means that an individual can accrue all of the costs to meet your family deductible ($3,500 in your case I believe) before coinsurance kicks in, there is no stopping at the individual deductible for one single member.  However, the embedded OOP Max means that one individual can only accrue up to the individual OOP Max that is associated with your plan, rather than accruing all of the way up to the family OOP Max.

I'm sure the internet has a better explaination, but I gave it my best shot :).  You should ask your HR rep if the deductibile is "true" or "embedded" for your answer.

[FiguringItOut]

Our insurance company uses the word "true" vs. "embedded" to describe what you are referring to.  In our case at work, the deductible is "true family" but the OOP Max is "embedded".  A "true family" deductible means that an individual can accrue all of the costs to meet your family deductible ($3,500 in your case I believe) before coinsurance kicks in, there is no stopping at the individual deductible for one single member.  However, the embedded OOP Max means that one individual can only accrue up to the individual OOP Max that is associated with your plan, rather than accruing all of the way up to the family OOP Max.

I'm sure the internet has a better explaination, but I gave it my best shot :).  You should ask your HR rep if the deductibile is "true" or "embedded" for your answer.

Well, my HR has been again less then helpful.  The person had no idea what 'true' vs 'embedded' deductible was or was able to explain how my deductible is supposed to work.  I am flabbergasted to be honest. 

I haven't had time to call insurance company again, but will try to do that later tonight or tomorrow.

This quest with the medical insurance is not fun.

[jorjor]

For an HSA-eligible family plan, the minimum family deductible must be met before any cost sharing kicks in or the plan isn't HSA eligible. That minimum deductible for family plans is $2,600 in 2016. In other words, if your plan has an embedded deductible with a $1,500 individual deductible, then it isn't HSA eligible because it's possible for cost-sharing to kick in before the $2,600 deductible is met.

A plan that had an individual deductible of $2,600 or more in 2016 could have an embedded deductible since the family deductible would be met.

Here is one of the first likes in Google that I found when I search HSA embedded deductible: http://www.ertelandcompany.com/wp-content/uploads/2014/09/HSAs-High-Deductible-Health-Plans-09-12-14.pdf

And an excerpt discussing what I describe above:

An HDHP is not required to include, or prohibited from including, an embedded deductible. However, a health plan does not qualify as an HDHP if there is an embedded deductible that is lower than the required minimum annual deductible for family coverage. Also, the HDHP must be designed to ensure that the embedded individual deductibles do not cause the plan to exceed the out-of-pocket maximum expense limit for family coverage.

Funny story: I am an actuary working for a consulting company that does quite a bit of work in health care and health insurance (not the consulting firm from the link an excerpt above). Our plan for 2015 originally had a $2,500/$4,000 individual/family deductible, and the deductible was embedded. A co-worker in my office realized the problem and contacted our HR department, saying that would eliminate HSA eligibility since the minimum family deductible was not being met. They looked into it and agreed, and they ended up increasing the individual deductible to $2,600 after open enrollment had already started. In a company that probably knows this stuff more than just about any collection of people anywhere, it somehow got by our HR department and the insurer that managed our coverage.

[FiguringItOut]

For an HSA-eligible family plan, the minimum family deductible must be met before any cost sharing kicks in or the plan isn't HSA eligible. That minimum deductible for family plans is $2,600 in 2016. In other words, if your plan has an embedded deductible with a $1,500 individual deductible, then it isn't HSA eligible because it's possible for cost-sharing to kick in before the $2,600 deductible is met.

A plan that had an individual deductible of $2,600 or more in 2016 could have an embedded deductible since the family deductible would be met.

Here is one of the first likes in Google that I found when I search HSA embedded deductible: http://www.ertelandcompany.com/wp-content/uploads/2014/09/HSAs-High-Deductible-Health-Plans-09-12-14.pdf

And an excerpt discussing what I describe above:

An HDHP is not required to include, or prohibited from including, an embedded deductible. However, a health plan does not qualify as an HDHP if there is an embedded deductible that is lower than the required minimum annual deductible for family coverage. Also, the HDHP must be designed to ensure that the embedded individual deductibles do not cause the plan to exceed the out-of-pocket maximum expense limit for family coverage.

Funny story: I am an actuary working for a consulting company that does quite a bit of work in health care and health insurance (not the consulting firm from the link an excerpt above). Our plan for 2015 originally had a $2,500/$4,000 individual/family deductible, and the deductible was embedded. A co-worker in my office realized the problem and contacted our HR department, saying that would eliminate HSA eligibility since the minimum family deductible was not being met. They looked into it and agreed, and they ended up increasing the individual deductible to $2,600 after open enrollment had already started. In a company that probably knows this stuff more than just about any collection of people anywhere, it somehow got by our HR department and the insurer that managed our coverage.

jorjor thank you for the explanation.

So if I understand this now, we will have to meet both mine and my daughter's deductibles ($1,500 each) at the very least before the insurance kicks in.  I am still not clear on what happens with the remaining $500 for $3,500 family deductible, but I suppose we'll find out sometime in March or April when the individual deductibles will be met.   

Thank you.

[jorjor]

For an HSA-eligible family plan, the minimum family deductible must be met before any cost sharing kicks in or the plan isn't HSA eligible. That minimum deductible for family plans is $2,600 in 2016. In other words, if your plan has an embedded deductible with a $1,500 individual deductible, then it isn't HSA eligible because it's possible for cost-sharing to kick in before the $2,600 deductible is met.

A plan that had an individual deductible of $2,600 or more in 2016 could have an embedded deductible since the family deductible would be met.

Here is one of the first likes in Google that I found when I search HSA embedded deductible: http://www.ertelandcompany.com/wp-content/uploads/2014/09/HSAs-High-Deductible-Health-Plans-09-12-14.pdf

And an excerpt discussing what I describe above:

An HDHP is not required to include, or prohibited from including, an embedded deductible. However, a health plan does not qualify as an HDHP if there is an embedded deductible that is lower than the required minimum annual deductible for family coverage. Also, the HDHP must be designed to ensure that the embedded individual deductibles do not cause the plan to exceed the out-of-pocket maximum expense limit for family coverage.

Funny story: I am an actuary working for a consulting company that does quite a bit of work in health care and health insurance (not the consulting firm from the link an excerpt above). Our plan for 2015 originally had a $2,500/$4,000 individual/family deductible, and the deductible was embedded. A co-worker in my office realized the problem and contacted our HR department, saying that would eliminate HSA eligibility since the minimum family deductible was not being met. They looked into it and agreed, and they ended up increasing the individual deductible to $2,600 after open enrollment had already started. In a company that probably knows this stuff more than just about any collection of people anywhere, it somehow got by our HR department and the insurer that managed our coverage.

jorjor thank you for the explanation.

So if I understand this now, we will have to meet both mine and my daughter's deductibles ($1,500 each) at the very least before the insurance kicks in.  I am still not clear on what happens with the remaining $500 for $3,500 family deductible, but I suppose we'll find out sometime in March or April when the individual deductibles will be met.   

Thank you.

If it is a true/contract/non-embedded family deductible, then the insurance wouldn't kick in until the full $3,500 family deductible is met, whether those claims are concentrated among one person or spread among multiple members.

It isn't necessarily binary though. You can have a plan that has a $1,500/$3,500 IND/FAM deductible, but an single person in a family plan can have a $2,600 deductible to preserve HSA-ness. That's less likely. The most likely scenario based on HSA rules and what is common in the market is that you'll meet the $3,500 deductible before anything is paid (other than preventive care).

[ABC123]

I have a HDHP through my insurance, and the kids are on my plan.  Here, the individual deductible only applies to plans with just one person.  So if the kids weren't on my plan, I would have the individual deductible.  We have to meet the full family deductible before anyone gets just charged the coinsurance.  I think it is $1500 individual/$3000 family - so even if just one person needs care, they would still have to reach $3000 before the deductible is met.

[FiguringItOut]

I have a HDHP through my insurance, and the kids are on my plan.  Here, the individual deductible only applies to plans with just one person.  So if the kids weren't on my plan, I would have the individual deductible.  We have to meet the full family deductible before anyone gets just charged the coinsurance.  I think it is $1500 individual/$3000 family - so even if just one person needs care, they would still have to reach $3000 before the deductible is met.

Thank you.  This is pretty much what I've been explained after I spend half hour on the phone with the insurance.  Unbelievable how unhelpful these phone reps are.