r/HealthInsurance • u/93ParkAvenueUltra • Apr 09 '25

Plan Choice Suggestions Please explain like I'm 5

I have two health plans to choose from.

Plan A: $11856 per year premium. Deductible is $1600 with 20% coinsurance afterward. Out of pocket max is $6250. Plan Type: PS1

Plan B: $8050 per year premium. Deductible is $7500. Out of pocket max is $7500. Plan Type: EP1

My wife wants to have another baby, but the last one she had pre-eclampsia and we spent a total of 3 weeks in the hospital.I am fairly confident that she will hit the Out of pocket max.

Question 1: Why does Plan B look like the better bet even though it is cheaper than Plan A? Am I missing something?

Question 2: Is the "out of pocket max" truly a hard limit? Or is there some way for them to weasel more money from us after that?

Question 3: I Plan to put the premium difference ($3805) in a HSA to offset the birth costs. Would it be wiser to go with plan A with less HSA savings? Or plan B with more HSA savings?

Sorry for the long first post and thanks for reading! I've been wracking my brain for hours and I think that I just need another set of eyes on it.

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u/[deleted] Apr 09 '25

Is the deductible and max oop family amount or individual

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u/93ParkAvenueUltra Apr 09 '25

Individual. The way I understand it is that each person has their own individual deductible, then it's 100% covered for that individual on the plan.

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u/[deleted] Apr 09 '25

Is one a PPO and one a HMO? Does your employer sponsor any of the money into the HSA? Are you positive both plans have HSA? Sometimes the better plans do a FSA. Lots of things to consider like besides the pregnancy do you or your spouse have any other health issues?

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u/93ParkAvenueUltra Apr 09 '25

Both plans are considered High deductible and offer HSA. I currently contribute $4500 yearly to my HSA. I dont know if it is ppo or hmo. It only says PS1 and EP1 under their respective plan types.

We are fairly young with no heath issues. If it wasn't for the thought of a baby we would do the cheapest plan possible.

Edit: I'm not sure what you mean by employer sponsor. They don't contribute to it at all.

1

u/6g_fiber Apr 09 '25

Your employer doesn’t contribute anything?? If that’s the case you should do a marketplace plan. Have you recently had a qualifying event? (Like the recent loss of your previous insurance?)

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u/93ParkAvenueUltra Apr 09 '25

Yes, my wife did! I've considered it, but I'm unsure if those plans are also pre-tax dollars.

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u/dehydratedsilica Apr 09 '25

In general, they are not. (They can be if you qualify for the self-employed health insurance deduction.)

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u/sbourke07 Apr 09 '25

Typically it is a family deductible and family out of pocket maximum. I used to have a high deductible plan that was $3000 deductible for my family and then 20% coinsurance until the $6000 out of pocket maximum was hit. After hitting that then everything the plan covered was free. I also had a super expensive medication that had a copay card so I hit my max by February 1 and typically only paid $50 a year of my own money for all medical expenses including insurance premiums.

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u/93ParkAvenueUltra Apr 09 '25

So if you are on a family plan does the out of pocket max for an individual on the plan raise to the family amount? For easy math, let's say the plan has a 10k family and 5k individual OOP max. I hit the 5k mark in June but my wife has only spent 1k. If I have a 2k medical bill in July, do I have to pay? Or is it covered since I hit my individual OOP max?

1

u/yuricat16 Apr 09 '25

It depends on how the plan is structured. For some plans (like the ones I’ve always had), if an individual member reaches the OOP max, all covered services are paid for that individual, regardless of whether the family has met the deductible or OOP max.

For other plans, the family limits for deductible and OOP max need to be met, and the individual limits are only applicable when there is only one person on the policy.

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u/sbourke07 Apr 09 '25

You still have to pay. The individual ones are meaningless for the family plan.