medical insurance advice neede

[Nik's Mom]

Hi,
I hope this can stay on topic without getting into politics. I need some help. DH's company announced changes in health insurance for 2011. The prices have significantly increased.

We now only have 2 choices. One is a ppo, but is double from what we are paying this year. And you can no longer have an FSA account with it. Our 2nd choice is cheaper, but prescriptions are not covered until a $3000 deductible has been met, plus all medical expenses must be paid by us until that $3000 deductible is met. After the deductible is met, we would be responsible for 20% of all charges. Now, the good thing with this program is that you can have an FSA account.

I have never had an insurance that required us to pay all expenses until deductibles are met. That makes me really nervous. Plus, ds takes 2 dfferent meds, so we would have the added burden on paying for those meds out of pocket. I was hoping to hear from people who are familiar with this type of insurance? I'm really nervous about picking because I have no experience with this type.

Here is a little background that might shed some light on our situation. DH and I are healthy, as are our children. Our sons are autistic, and there are times when we may have to see a therapist regarding one of them. My youngest ds has add and anxiety problems and he takes medication for that. Right now, it is prescribed by his doctor.

So, I'd love to get some non-political feedback. Thanks!

 

[Jaime4004]

We have had a similar plan for years. $3000 family deductible, very low monthly cost. We have to pay out of pocket for everything (prescriptions also) except for one routine physical exam/year, until the deductible is met. It's hard to adjust to, but now that we've been doing it for years, every month I put aside $200 to put towards the next year's deductible, that way I already have the money ready. The reason we did this was because one January, my 2 y.o. had a 5 day hospital stay, so we ended up with the entire $3000 bill due that month . The good thing was that I paid for nothing else the entire year... But it wasn't fun to come up with the deductible money all up front!

 

[sksjasams]

Even though it is more expensive, I would go with the ppo. I wouldn't like the high deductable of the other plan, no prescription coverage, and even worse the fact that you would have to pay 20% even after the deductable is met. The unknown, unexpected costs of that plan are just too scary for me. I would rather have a planned expense each month.

 

[Nik's Mom]

I know, sksjasams. That is what I'm nervous about. I guess we could put $3000 into the FSA account to cover that. Oh, the 20% is with either insurance though. Man, it is so hard to figure out what is best. If we pick the more expensive one, it will be like dh is getting a pay cut.

 

[disneywithfive]

You really need to get the details of the ppo plan. Our daughter gets ST & OT but they get applied to our deductible, not the copays that are usually associated with office visits. Plus we are limited to 20 per calendar year. I know, though, that having a child with medical needs can get draining. Prior to our daughters medical needs, we had a traditional health plan (sounds like the other plan you are describing). It had a $5,000 deductible but after that everything would have been covered 100%. Check to see if there is an additional out of pocket maximum. For example, you pay the first $3,000 then you pay 20% up to ??????. Is there a max. If so, add up the additional premiums that you would pay with the PPO and see if it will cover your additional out of pocket expenses. Sorry, I imagine this sounds clear as mud - it's really a complicated process when you have a true need for medical insurance.

 

[Nik's Mom]

You really need to get the details of the ppo plan. Our daughter gets ST & OT but they get applied to our deductible, not the copays that are usually associated with office visits. Plus we are limited to 20 per calendar year. I know, though, that having a child with medical needs can get draining. Prior to our daughters medical needs, we had a traditional health plan (sounds like the other plan you are describing). It had a $5,000 deductible but after that everything would have been covered 100%. Check to see if there is an additional out of pocket maximum. For example, you pay the first $3,000 then you pay 20% up to ??????. Is there a max. If so, add up the additional premiums that you would pay with the PPO and see if it will cover your additional out of pocket expenses. Sorry, I imagine this sounds clear as mud - it's really a complicated process when you have a true need for medical insurance.

That is very helpful! Thanks. It looks like there is a $6000 cap as opposed to the tradional ppo with a $3900 cap. I appreciate everyone's comments. Thanks!

 

[sjs314]

My DH always carried the Insurance for our Family, normally I looked over the options during open season and chose what I thought was best, but one year the costs went up and DH listened to some of his "buddies" at work and chose a plan with a high deductable. January rolled around on the new plan and it was time for eldest DS physical, we paid then a few weeks later they both became ill with strep , more perscriptions , youngest DS did not repsond to the first anitbiotics so the Dr perscribed something different, I stopped at the atm and took out $100 as I waited for the perscription the Pharmacist came over as he tried to run it thru our insurance and said to me we had to pay out of pocket, I nodded saying yes I knew we had not met our deductable yet, he looked at me and said it is expensive, I asked how much he rattled off a figure $200+ This was back in the late '80's and $200 was a lot of money back then. I had no choice but to pay for it but I made sure after that we never again had to meet a deductable before the insurance paid again.

We are older now but my meds run $800-900 per month if it was not for insurance and I had to meet a deductable before they paid now, I would not be able to afford my meds and eat too.

I would much rather pay a higher premium than ever take the chance of being caught short and have to pay a high out of pocket cost.

 

[Nik's Mom]

That is another good point, sjs314. My youngest ds is on 2 medications. One of them has no generic available and would be $135 a month without insurance. It may not sound like a lot for some people, but that is a lot to me.

 

[disneywithfive]

I forgot to mention that not only do I have a daughter with medical needs but I'm a Human Resource Manager so I'm all to familiar with insurance. LOL!!

So the PPO's premiums are twice what you are paying now but what is the deductible and is there any additional out of pocket expenses once the deductible is met. ie) 80% co, 20% individual until ???? Also, do you have RX copays? I know that you mentioned a $3,900 cap but how is that broken down.

The traditional plan's premiums are about the same, with a $3,000 ded, additional $3000 out of pocket (80/20 split) and all RX going to deductible and oop before insurance will pay 100%.

What is the difference in premiums with the PPO from last year to this year?

 

[cvjw]

My DH's whole company went to the second option of insurance last year - no one has any other choice for insurance. The monthly premiums went down for us, but we have to meet a $2000 family deductible, or $650 per person deductible. The plan then pays 85% of the rest of the claims. It has certainly taken some getting used to, but the company did it as a cost saving method. Now that the employees have to pay up front for doctors visits (not well-checks), it makes us only go to the doctor when it is truly needed.

 

[RMAMom]

Before making a finale decision you may want to call the new insurance and be sure that your Doc's are in network. They may not be in network with one and OK in the other. For instance my Dr is in network with BC & BS HMO plans but not the PPO plans. Just my 2¢

 

[Juliee8]

I would check into the ppo more before you make a decision. You definately want to make sure that the doctors & hospitals that you go to are included in the plan. The other thing that I would tkae into consideration is how much that you use your FSA. I know that you said that your sons are autistic, so I am assuming that you probably use it alot.

I just noticed that you are from Overland Park, we were just there last week to take my son to his doctors appointment! Oh and of course dd to American Girl!

 

[Nik's Mom]

More good information from you guys. I really appreciate it. Disneywithfive, the deductible with the traditional ppo, it is $2000 per family. And we would have to cover 20% of additional expenses, but the brochure does not say if that is per person or famiy. The total out of pocket expenses would max out at $4000 per family. The difference in price is $1968 per year between the 2 types of insurance. The traditional ppo that we currently have has increased in price by 40%. I won't know the actual dollar amount until Friday though, when dh attends the benefit meeting. Right now, all I have is this little brochure. So frustrating.

Juliee8, I have boys so no American Girl from me, but I heard the new store is great. I love our little town.

 

[Juliee8]

I absolutely love the area!!! Our son is also autistic and we have been traveling there every couple of months to my son's doctor for the past 2 years, so I am getting to know the area really well!

 

[mrsklamc]

Remember that what is allowed under FSA spending will be changing as well.

Personally, I don't mind having high deductible plans as long as there is a clearly stated out of pocket maximum that I know I can cover. I look at it this way- Insurance premiums, once I pay them, I KNOW they are gone. If I have a high deductible plan with a lower premium, I can put the rest of that money in the bank and *hope* I don't have to use it.

But if you don't have savings or can't build up savings, high deductible plans are probably not a good idea.

 

[Mommee]

OP, we pay for our prescriptions until the deductible is met, but it goes toward the deductible and then is paid in full (we pay extra per month for that instead of the 80/20) once we hit that deductible. We went with the high-deductible plan after having our HMO co-pay us to death--from this year compared to the year before we're saving over $4000 between lower monthly premium and the cap on OOP. Our HMO had a cap, but almost everything outside of a hospitalization did not count toward it. Our high-deductible plan includes everything towards it.

We always set aside enough in our HSA to cover our deductible and uncovered costs. It's automatically deducted from DH's paycheck. I would rather pay myself (and have that money available to me if I don't use it) than pay the insurance company.

 

[Zachsmom4]

Also remember that if you choose to have the FSA next year, the maximum will be $2500. This is a new addition to the health care bill.

 

[Nik's Mom]

Also remember that if you choose to have the FSA next year, the maximum will be $2500. This is a new addition to the health care bill.

I'm reading the brochure and it says we can have up to $6150 per family in the account. But I'm reading the fine print and it says it's an HSA account. I think this year we have an FSA account. I better make sure on this before we decide. While we have a personal savings account, I don't want it to be wiped out by medical expenses in one year.

I also just checked on the prescriptions and it looks like the amounts we pay will go toward the deductible.

Thanks for everyone giving me some in-put on this. You have helped shed light on this for me.

 

[mistysue]

OP- how much are the premiums you would have to pay?
This makes a HUGE difference. If you are going to pay $6,000/year more for the plan that would save you $3,000- that obviously makes no sense. But if there is a $1,000 difference between the two for the year, that would also give an easy answer.

You said it doubled, but what portion do you pay vs what the employer pays?

 

[dhardawa]

High deductible plans have an HSA, not an FSA. This is good because the money will carry over from year to year, unlike a FSA.

I would also need to know what the premiums on the two are. We have no choice other than a high deductible plan and I hate it. When something happens, you are stuck paying everything out of pocket. I have medication I need that I don't take because it is $180 a month and I'd have to pay it all. Last spring, I had a kidney stone and ended up in the ER. With a PPO, that would have cost me $50 - $100. With the high deductible plan, it cost me close to $4,000.