High out of network costs, which HSA HDHP plan?

[capestorm]

Update 1: I found out that cross-accumulation applies (e.g. amounts towards the OON deductible apply to the IN deductible), but didn't figure out how to put that into the calculator.

https://www.reddit.com/r/HealthInsurance/comments/164xq2i/_/jz6yri0

and I fixed the calculator

https://www.reddit.com/r/HealthInsurance/comments/164xq2i/_/jzca0y9

I finally found out that 100% of my expected out of network costs would go toward my OON deductible (i.e. none of it seems to be balance billed), at least based on the claims that already went through.

I'm trying to decide which HDHP plan to choose for the remainder of this year (11 paychecks).

Premium (per paycheck, every 2 weeks)	40.15	11.54
In-Network Deductible	1500	3250
In-Network Out-of-Pocket Maximum	5000	6500
In-Network Coinsurance (Amount NOT covered)	20%	20%
Employer HSA Contribution (prorated*)	608.33	400
My HSA Contribution	3642.67	3850
Out-of-Network Deductible	1500	3250
Out-of-Network Out-of-Pocket Maximum	N/A	N/A
Out-of-Network Coinsurance (Amount NOT covered)	40%	40%
Total Premium (prorated for 11 paychecks)	441.65	126.94

Premium HSA HDHP
Basic HSA HDHP

My calculations (updated since last post):

1000	2000	-127.87	-442.58
1000	2500	-427.87	-742.58

In Network Costs
Out Of Network Costs
Plan 1 - Plan 2
Plan 1 - Plan 2 w/o premiums

The "w/o premiums" column is because I can pay all of the coinsurances with my HSA, but apparently not any of the premiums.

Full calculator here: https://docs.google.com/spreadsheets/d/1zOLrOFp-7WxRT0eX31QPm1VSJeTnNDYXTyP6q9tO6B0/edit?usp=sharing (Updated to fix In-Network calculations with OOP max)
https://docs.google.com/spreadsheet...ouid=118254286588284376095&rtpof=true&sd=true

Based on my results, it seems like the Premium HSA HDHP is slightly better, but I don't really know how to consider factors like opportunity cost. It seems like it's even better up until a narrow range of in network costs (~$5500 - $6500), which I doubt I'll hit.

(*Note: The "608.33" employer HSA contribution is based a previous employer contribution of $400, +$208.33 prorated monthly, based on an employer contribution of $500/year.)

 

[capestorm]

Hi everyone, still thinking about the responses and thanks for the comments! But I found out something that will require me to update my calculator again.
Apparently amounts that go toward my OON deductible will also go toward my IN deductible.

 

[capestorm]

Unfortunately, adding cross accumulation to my calculator got too complicated for me. Based on my understanding of it though, it would only save me money, and not cost me anything more, and I don't suspect it would make that much of a difference between the plans since I'm not needing to spend that much IN. Plus, I don't think I'd hit it in with the Basic Plan.

I think it's complicated because it depends on when my OON payments are, but they are spread over the year instead of all at once. If I hit my OON early, then because that means I also hit my IN deductible, which means coinsurance will apply then. That is beyond my ability to use spreadsheets.

 

[foreverthankful]

@capestorm I'm not sure what you're trying to figure out here. The spreadsheet looks impressive, but I don't know what your inputs are doing.

I also wouldn't recommend going out of network if you can avoid it.

Let's say a doctor visit costs $100 and the insurance company says the "allowable amount" is $60. On the HSA plan, in network, you'd pay that $60 and the in-network doctor can't balance bill you for the rest of that, but the same visit Out of Network, the out of network doctor can then send you another bill for the other $40.

Yes, on an HSA, where services and treatment are coinsurance based, not copay based, all fees you pay would track to both your Deductible and OOPM. (respectfully that is- all In network tracks towards In network and all out of network tracks to out of network).

The only real way to figure out which plan is "better" is to factor in what you expect to use your insurance for- how many doctor visits, how many other services, any Rx needs, etc.

 

[capestorm]

@foreverthankful

The spreadsheet looks impressive, but I don't know what your inputs are doing.

Haha no problem, and thanks. I'll try to explain. The input columns/rows that matter are that I estimate $1,000ish or less in network, and $2,000ish in out of network costs. These are the first 2 columns under the "Input" section, and I highlighted the rows that I think are most likely.

Then, the outputs that matter are "Plan 1 - Plan 2 (Negative/Green means Plan 1 is better)" and maybe "Plan 1 - Plan 2 without Premiums".

The rest is kind of extraneous, mostly because I'm still learning Excel, but I'll be using this spreadsheet for future years too.

I also wouldn't recommend going out of network if you can avoid it.

Unfortunately, I can't in this case, at least not with this year. I'll reconsider my options for next year.

Let's say a doctor visit costs $100 and the insurance company says the "allowable amount" is $60.

Based on the claims I've submitted, the OON costs are all going to be within the allowable amount. i.e., the cost was $150, and $150 of it goes to my OON deductible. So while I'm still paying the $150 until I hit that deductible, I have an idea of when I'll hit it (after ~10 appointments in Plan 1 which has a OON deductible of $1,500). I don't suspect that the allowable amount would change over time?

The only real way to figure out which plan is "better" is to factor in what you expect to use your insurance for- how many doctor visits, how many other services, any Rx needs, etc.

Yeah, I'm expecting to spend at most another $1000 in IN costs this year, and about $2000 in OON. For IN, it's about $400 ~ $600 at most based on my existing prescriptions and appointments. (With the calculator, anything below $1000 is approximately the same difference between plans, because it doesn't really start changing until $1500, Plan 1's deductible).

According to my calculator, Plan 1 is approximately better for any costs less than $5000, and any costs above $7000. It looks like the same trend for OON costs.

 

[pdg90601]

@capestorm How do you know that you won't be balanced billed?

 

[capestorm]

@pdg90601 I'm assuming that because it will be repeats of the same type of appointment for the rest of the year, and I've submitted claims for it, and they haven't been balance billed yet (i.e., $150 of the $150 that it cost for the appointment, went towards my OON deductible).

Based on what I know from the doctor/facility, I don't expect them to change their prices this year either.

It's possible I could get other, unrelated OON costs that do get balance billed, but I'm doubtful that would happen.

I did try asking my insurance about how to estimate a OON cost prior to the claim, and they said it wasn't really possible, so this is all my best guess.

 

[pdg90601]

@capestorm This is a very cool spreadsheet and I say that as someone who works in this field & makes my own complicated spreadsheets for this very purpose.

That said, some of your inputs are confusing and I think it comes down to what you mean by costs. It looks like you are equating 'cost' with what you as an individual pay. The part that sticks out is the in-network costs at $5k and then and $5500--estimated in-network costs at $5k are $2200, but at $5500 jumps to $5000? I suspect this has to do with how you are calculating the coinsurance.

Also I suggest moving the tax savings to a different place because that adds a layer of confusion.

Providers who are OON can balance bill you at any time. It is not uncommon to get a bill for services a year later.

 

[capestorm]

@pdg90601 Thanks a bunch for looking at it, I appreciate the feedback! I did indeed make a mistake in calculating the total in-network totals. I was comparing the initial Estimated In-Network column to the OOP max, rather than using the calculated costs considering coinsurance.

e.g., for an Estimated IN Rate (before insurance) of $5500 on Plan 1:

• The old calculation compared the OOP Max to Estimated IN (wrong usage), so because $5500 > $5000, it would = $5000 (wrong result).
• Now, it gets the minimum between the OOP max, and the calculated individual pay I owe with coinsurance ($1500 + ($5500 - $1500)*.2 = $2300), being the $2300 in this case.

This is based on my understanding from https://www.procedurerates.com/calculator about the OOP max. It seems that the IN rates before insurance would have to total $19,000 ($1500 + (x - $1500)*.2 = $5000).

https://docs.google.com/spreadsheets/d/1zOLrOFp-7WxRT0eX31QPm1VSJeTnNDYXTyP6q9tO6B0/edit?usp=sharing
I've updated the calculator (and made a section without the tax savings), and I'm mostly baffled that Plan 1 looks even better now with this fix (which I'm assuming is a better choice, when all is ideal). My deadline on the choice is tomorrow.

I'll keep that in mind about OON as well, thanks!