Help compare to current plan?

[miguel1]

Hi! Thanks in advance for the help, I’m completely lost. Plan 1 is our current plan. Spouse got a new job which has decent coverage (Plan 2) but it’s like comparing apples and oranges to me!

Family Coverage: 2 adults, 2 children. No more anticipated.
1 adult and 1 child have a heart condition; currently on maintained well with medication. Anticipate surgery in future. Child also has respiratory issues; hopefully maintained now. Does have history of 5+ day PICU stays. I know Plan 2’s deductibles and monthly premiums are so much lower but the unlimited max out of pocket for out of network scares me. With a child with a history of hospitalization, I’m just fearful we are on vacation, out of network and get slammed with a high bill! I know I have to check current medication for new plan. All input is helpful! In NJ if that matters.

Plan 1: Horizon BCBS – PPO
Monthly Premium: $392
HDHP – Employer funds HSA $2,500/calendar year
Currently maxing out HSA additional $437.50/month
In-Network:
· Deductible: $2,000/$4,000
· Max Out of Pocket: $5,100/$10,200
· Coinsurance: 20% after deductible
· PCP Visit: 20% after deductible
· Specialist Visit: 20% after deductible
· Emergency Room: 20% after deductible
· Urgent Care: 20% after deductible
· Careonline: $0 after deductible
· Prescription:
o Generic: 15% after deductible
o Preferred Brand Name: 15% after deductible
o Non-Preferred Brand Name: 30% after deductible
Out of Network:
· Deductible: $2,000/$4,000
· Max Out of Pocket: $5,100/$10,200
· Coinsurance: 40% of R&C after deductible
· PCP Visit: 40% after deductible
· Specialist Visit: 40% after deductible
· Emergency Room: 20% after deductible
· Urgent Care: 40% after deductible
· Careonline: N/A
· Prescription:
o Generic: 40% after deductible
o Preferred Brand Name: 40% after deductible
o Non-Preferred Brand Name: 40% after deductible

Plan 2: Cigna Open Access Plus
Monthly Premium: $192
In-Network:
· Deductible: $400/$800
· Max Out of Pocket: $1,500/$3,500
· Coinsurance: 10% after deductible
· PCP Visit: 10% after deductible
· Specialist Visit: 10% after deductible
· Emergency Room: $50 copay; 10% after deductible
· Urgent Care: 10% after deductible
· Careonline: N/A
· Prescription (deductible does not apply):
o Generic: $30 copay/prescription (90 day)
o Preferred Brand Name: $60 copay/prescription (90 day)
o Non-Preferred Brand Name: $100 copay/prescription (90 day)
Out of Network:
· Deductible: $5,000/$10,000
· Max Out of Pocket: unlimited
· Coinsurance: 50%
· PCP Visit: 50% after deductible
· Specialist Visit: 50% after deductible
· Emergency Room: $50 copay; 10% after deductible
· Urgent Care: 50% after deductible
· Careonline: N/A
· Prescription:
o Generic: not covered
o Preferred Brand Name: not covered
o Non-Preferred Brand Name: not covered

 

[ngocvncom]

@miguel1 Out of network services always have an unlimited maximum. The OON OOP max on your BCBS plan only applies to the amount of out of network cost sharing you have to pay before BCBS starts paying 100% of their allowed amount. But you are still on the hook for balance billing….that doesn’t count towards your OOP max nor is their any limit on it.

But for either plan, that’s for non-emergency services. Every plan…even ones that have no out of network coverage at all, have to cover out of network emergencies at the in-network level.

Your new plan has much lower premiums and cost shares and is going to save you money. But it’s a different insurance network, so you may need to find new doctors. You don’t get the tax advantage of an HSA anymore, but if the new employer has an FSA you can take advantage of that.

 

[miguel1]

@ngocvncom Thank you! I think only one of my son’s doctors doesn’t participate but there are others in that speciality nearby that do.

I can still use my current HSA until the funds run out, correct?

 

[ngocvncom]

@miguel1 Yes, the HSA account is yours, you only need the HDHP to contribute. You can distribute whenever you want on qualified medical expenses.

 

[miguel1]

@ngocvncom Also! Does changing to my spouse’s insurance count as a qualifying life event to be able to drop my insurance? Or are we stuck in current or paying both until open enrollment? I’ve looked at Qualifying Life Event definitions and it’s about loss insurance, which I’m not.

 

[ngocvncom]

@miguel1 Gaining coverage under your spouses plan is a qualifying event that permits the employer to allow you to drop midyear without jeopardizing the tax advantaged status of health insurance premiums. But it doesn't require them to allow it, if they don't feel like dealing with the administrative hassle. You're going to have to check with your HR to see what your company's policy is.

 

[miguel1]

@ngocvncom Thank you so much for this feedback!

 

[stars_andwonder]

@miguel1 you can 100% control staying in network so I wouldn't put too much weight on a OON benefit on a PPO plan. Honestly we almost never sell a PPO plan these days because with a national "in network" benefit with it's own deductible, who the hell can afford to go OON with a separate deductible and so much cost sharing?? Not many... For this reason we're EPO all dang day!

 

[miguel1]

@stars_andwonder Thank you so much!