Choosing a marketplace plan between coinsurance and copay

[starflower]

Hello, I’m stuck between two plans. They cost the exact same amount. The main difference is that Plan A has copays where Plan B has coinsurance.

For a specialist (under Tier 1 pricing) visit Plan A charges $40 where Plan B charges 20% coinsurance. For a primary visit Plan A charges $20 copay and Plan B charges $15 copay. Under Tier 2, Plan A copays are $75 and $50 respectively and Plan B coinsurance are 40% for both.

Plan A has an OOP maximum of $2500 and Plan B has an OOP max of $2000.

I see a specialist either virtually or in person about every 6 weeks for a condition I have. Which plan sounds like the right one? They’re both Amerihealth Advantage.

 

[minnieys]

@starflower It depends on several things like is your specialist tier 1 or 2? Do you have a deductible? Is this specialist your only health expense? Are the OOPMs the same for both tiers? What is the negotiated rate for a specialist visit in total? (You should have this information on an EOB from a recent visit)

 

[starflower]

@minnieys Specialist is Tier 2*. The deductible for Plan A is 400 and for Plan B is 800. Other than the specialist I only go if I’m sick (and can’t just suck it up at home, like I need antibiotics) or for an annual visit. The negotiated rate is either 250 or 500 based on the visit type. The OOP max are the same for both tiers in each plan. It’s one OOPM per plan and same for the deductible. I also take four medicines a month with an injected medicine every 3 months.

ETA: for Plan A copays take place before the deductible. For Plan B they don’t kick in until after the deductible.

 

[minnieys]

@starflower My guess is that you're someone who will probably hit OOPM and thus should take plan B's lower OOPM. But it's hard to do the math without knowing how the pharmacy end of things works for your plans. In your shoes I'd make a spreadsheet with all my expected costs and see how it goes in an average year and a catastrophic year.

 

[heretichermes]

@starflower Yup. If you will hit OOPM do B otherwise do A.

 

[kohajesemen]

@starflower Do you normally hit your out of pocket maximum? If yes, then choose the OOP max of $2000. If not, and it's not close to $2,000, then I'd consider plan A. $40x9 is $540.

Have you confirmed your specialist is with this company?

I will say (I'm on Anthem in MO, so not same), my husband's neurology specialist co-insurance ended up being only $18.50! So way cheaper than $40. So if this were the same scenario, we'd save a significant amount with the co-insurance versus co-pay. This is about $80 less than we were paying under our prior employer sponsored insurance which had a huge monthly premium to boot! Marketplace plans are not always the worst.

 

[starflower]

@kohajesemen I have hit it before but it usually depends on what insurance I have. Last year plan had really low copays that almost never applied and a really low deductible with a high OOPM so I didn’t (I paid about $700 total plus so much in premiums) But in the past I have reached it around May.
My specialist is definitely approved by the company.

 

[kohajesemen]

@starflower I’d choose plan A then, because at least you know your frequent co-pay will always be $40. While $500 is a lot, it’s not a huge difference if you do in fact reach your OOP. Good luck!