Deductibles
Employee Only Coverage Deductibles in the HDHP + HSA Plan
In the HDHP + HSA Plan, you must meet the $1,500 deductible. After that, you pay coinsurance for the in-network services until you reach your out-of-pocket maximum.
Employee Only Coverage Deductibles in the PPO Plan
In the PPO Plan, you have a $750 deductible. After that, you pay coinsurance for in-network services until you reach your out-of-pocket maximum
Your copays for office visits, urgent care clinics and prescription drugs do not count toward your deductible.
All Other Coverage Deductibles in the HDHP + HSA Plan
In the HDHP + HSA Plan, the family must meet the $3,000 deductible. After that, you pay coinsurance for the in-network services until you reach your out-of-pocket maximum.
All Other Coverage Deductibles in the PPO Plan
In the PPO Plan, each covered family member has an individual deductible. When a family member has spent $750, he or she begins to pay coinsurance for in-network services. Meanwhile, if other family members need care, they must meet their individual deductible until the family has spent $1,500 as a family unit. After that you pay coinsurance until you reach your out-of-pocket maximum
Your copays for office visits, urgent care clinics and prescription drugs do not count toward your deductible.
Deductible In Action
Let's look at how spending on healthcare would differ throughout the year depending on their choice between the PPO and the HDHP + HSA plans for a family. The family includes Hank, his spouse, Maria, and their children, Ethan and Alexis.
| RATE* | HDHP + HSA PLAN DEDUCTIBLES IN ACTION - $3,000 deductible | PPO PLAN DEDUCTIBLES IN ACTION $1,500 Family $750 individual embedded deductible |
|---|---|---|
| January - Everyone gets an annual physical which included immunizations for the kids. $1,600 ($400 each x 4) |
$0 Enable Midstream pays 100% of annual physicians and childhood immunizations. |
$0 Enable Midstream pays 100% of annual physicians and childhood immunizations. |
| Early March - Ethan goes to the ER with a broken arm. $1,100 | $1,100 The family will pay the entire amount with the HDHP + HSA plan because the deductible has not been met. (Out-of-pocket year to date: $1100) |
$1,070 ($750 deductible + $250 ER copay + 20% coinsurance) The family has a $1,500 deductible, but each individual has an embedded $750 deductible. (Out-of-pocket year to date: $1,070) |
| Mid-March - Ethan has a follow-up with a doctor who sends him for a scan. $1,100 | $1,100 The family will pay the entire amount with the HDHP + HSA plan because the deductible has not been met. (Out-of-pocket year to date: $2,200) |
$225 ($25 doctor copay + 20% coinsurance for scan) The family will only be responsible for the copay and coinsurance. (Out-of-pocket year to date: $1,295) |
| May - Alexis visits the doctor and gets tested for strep and the flu. $200 |
$200 The family will pay the entire amount with the HDHP + HSA plan because the deductible has not been met. (Out-of-pocket year to date: $2,500) |
$45 ($25 doctor copay + 20% coinsurance for tests) The family will only be responsible for the copay and coinsurance. (Out-of-pocket year to date: $1,365) |
| Remainder of the year include 4 more doctor visits for the family. $400 |
$400 The family will pay the entire amount with the HDHP + HSA plan because the deductible has not been met. (Out-of-pocket year to date: $2,900) |
$100 ($25 doctor copay x 4) The family will only be responsible for the copay and coinsurance. (Out-of-pocket year to date: $1,465) |
| The family will have to spend another $100 before meeting their deductible. At that time, they would then been billed 10% of in-service network costs. | ||
| Additional PPO Premium cost* | +$3,000 | |
| Enable Midstream HSA contribution | ($1,000) | |
| Total cost for the year | $1,865 | $4,465 |
| *Approximate difference in premium cost between HDHP+HSA plan and PPO plan |
* Approximate BCBS In-Network Rates
Hank and Maria both have additional care throughout the year. In both plans they will continue to pay coinsurance any copays until they reach the family out-of-pocket maximum.