It is important to think carefully about which medical plan will be best for you and your family. Here are examples of out-of-pocket costs for three employees with different medical needs. Which employee is most like you and your family? See Which Medical Plan Is Best for You? to think through your own situation.
| Meet Sam: Single | |||
|---|---|---|---|
| • Age 25 • Typically very healthy • Generally visits a doctor once or twice a year |
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| During the year, Sam will visit his doctor for an annual physical and then again for a sore throat. The total cost for the services and medications he receives are $374: • 1 preventive doctor’s office visit: $172 ($0 cost to Sam) • 1 diagnostic doctor’s office visit: $127 • 1 Tier 2 antibiotic: $75. |
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| Costs to Sam: | |||
| Classic Plan | Health Savings Plan | Premier Plan | |
| Sam’s cost for preventive visit | $0 | $0 | $0 |
| Sam’s cost for office visit | $35 copay | $127 applied to deductible | $25 copay |
| Sam’s cost for Tier 2 prescription | $55 | $75 | $50 |
| Sam’s total out-of-pocket expenses | $90 | $202 | $75 |
| University’s contribution to Sam’s Health Savings Account | N/A | $420 | N/A |
| Net cost to Sam for care received | $90 | ($218) | $75 |
| Monthly premiums | Mid-range | Lowest | Highest |
With the Health Savings Plan, Sam will pay the lowest monthly premium available. If Sam is comfortable managing the Health Savings Account, the Health Savings Plan may be his best choice.
| Meet Jen and Mike: Family with young children | |||
|---|---|---|---|
| • Jen is age 34; Mike is age 36 • Their children are age 5 and 2 • They visit the pediatrician frequently for common child ailments |
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| Their daughter has tonsillitis. She has an outpatient tonsillectomy and is prescribed two Tier 2 antibiotics. One month later, she has a follow up visit with her doctor. Her total cost before the plan pays benefits is $4,061: • 1 outpatient surgery: $3,154 • 2 Tier 2 antibiotics: $780 • 1 doctor’s office visit: $127. Their son has pink eye and goes to urgent care to get a prescription. His total cost before the plan pays benefits is $188: • 1 urgent care visit: $155 • 1 Tier 1 antibiotic: $33. Plus, the whole family gets annual physicals: • 4 preventive doctor’s office visits: $688 ($0 cost to family). |
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| Costs to Jen and Mike: | |||
| Classic Plan | Health Savings Plan | Premier Plan | |
| Cost for preventive visits for each family member | $0 | $0 | $0 |
| Cost for daughter's outpatient surgery | $150 copay + $1,250 applied to deductible + $438 coinsurance = $1,838 | $2,700 applied to deductible + $45.40 coinsurance = $2,745.40 The daughter has met her deductible! | $650 applied to deductible + $500 coinsurance = $1,150 |
| Cost for daughter’s Tier 2 prescription | $55 copay x 2 = $110 | 10% coinsurance $78 applied to deductible | $50 copay x 2 = $100 |
| Cost for daughter’s office visit | $35 copay | 10% coinsurance $12.70 applied to deductible | $25 copay |
| Cost of son's urgent care visit | $55 copay | $155 applied to deductible | $50 copay |
| Cost for son’s Tier 1 prescription | $15 copay | $33 applied to deductible | $10 copay |
| Jen and Mike’s total out-of-pocket expenses | $2,053 | $3,024.10 | $1,335 |
| University’s contribution to Health Savings Account | N/A | $840 | N/A |
| Net cost to Jen and Mike for care received | $2,053 | $2,184.10 | $1,335 |
| Monthly premiums | Mid-range | Lowest | Highest |
Jen and Mike have a high cost at the beginning of the year with their daughter’s tonsillectomy and reach her deductible early on for all three plans. However, under the Health Savings Plan they have not met the family deductible so their son’s urgent care visit and Tier 1 prescription will still apply to that. They will have the lowest out-of-pocket expenses with the Classic and Premier Plans. The Health Savings Plan will require Jen and Mike to pay all of the cost until their deductible is met, which may be a concern to them. It will be important for them to consider this as well as factor in their premium costs in order to decide between the plans, since the Premier Plan premium is the highest.
| Meet Barry and Wanda: Empty Nesters | |||
|---|---|---|---|
| • Wanda is 58 years old—she’s starting to feel the effects of arthritis • Barry is 63 years old—he has a bad back and high blood pressure • Their children are grown and living on their own |
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| Barry suffers a stroke and Wanda calls an ambulance. After recovering, he starts regular check-up visits with his doctor. His total cost before the plan pays benefits is $19,856: • 1 ambulance: $1,040 • 1 emergency room visit: $1,233 • 4 days in the hospital: $10,876 • 1 Tier 3 medication: $2,980 • 3 specialist diagnostic doctor’s office visits: $381 • 14 physical therapy visits: $3,346 |
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| Cost to Barry and Wanda | |||
| Classic Plan | Health Savings Plan | Premier Plan | |
| Barry’s cost for ambulance | $0 (copay waived if admitted) | $1,040 applied to deductible | $0 (copay waived if admitted) |
| Barry’s cost for emergency room visit | $0 (copay waived if admitted) | $1,233 applied to deductible | $0 (copay waived if admitted |
| Barry’s cost for hospital stay | $300 copay + $1,250 applied to deductible + 25% coinsurance $300 + $1,250 + $2,331= $3,881 Barry has met his deductible! | $427 applied to deductible + 10% coinsurance $427 + $1,044 = $1,471 Barry has met his deductible! | $300 copay |
| Barry’s cost for Tier 3 medication | $90 copay | 10% coinsurance $298 | $80 copay |
| Barry’s cost for 3 specialist visits | $55 copay x 3 = $165 | 10% coinsurance $38 | $45 copay x 3 = $135 |
| Barry’s cost for 14 physical therapy visits | $35 copay x 14 + 25% coinsurance $490 + $714 = $1,204 Barry has met his medical OOP maximum! | 10% coinsurance $335 | $25 copay x 14 + $650 applied to deductible + 20% coinsurance $350 + $650 + $469 = $1,469 Barry has met his deductible! |
| University’s contribution to Health Savings Account | N/A | $840 | N/A |
| Net cost to Wanda and Barry for care received | $5,340 | $3,575 | $1,984 |
| Monthly premiums | Mid-range | Lowest | Highest |
Since Barry and Wanda have high surgery and emergency room expenses, the Premier Plan may save them the most money. However, if they are comfortable with their out-of-pocket expenses, they should consider the monthly premiums in their overall evaluation.