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Meet "Maria"

Maria is single, age 28 and an avid runner and sports fan. She was recently hired by VMware and carefully watches her health and health care costs. Her doctor is in the Aetna network. The following describes how the HSA PPO would work in 2018 for Maria.

  Premium (per paycheck) $0
  Coverage Employee Only
  HSA Contribution by VMware $750
  Employee-only deductible $1,500
  Coinsurance 10% for in-network medical services after deductible; 10%/15%/20% (generic/brand/non-formulary) for prescription drugs, after deductible
30% for out-of-network services, after deductible
  Out of Pocket Maximum $2,500 for in-network services
$6,000 for out-of-network services

2018 was an eventful year for Maria. She injured her right ankle during a half-marathon, requiring three doctor visits for treatment, and three formulary brand-name prescriptions. The following shows how the plan covered the costs for these services.

Services Used in 2018 Total Costs Amount paid from Maria's HSA Amount paid by the plan Amount paid by Maria Amount applied toward the $1,500 individual deductible Amount applied toward the individual OOP maximum
Annual physical, lab tests, routine gynecological care exam (in-network) $770 $0 $770
(100% covered preventive care)
$0 $0 $0
Three (3) doctor visits (in-network) $555 $555 $0 $0 $555 $555
X-Rays (in-network) $545 $195 $0 $350 $545 $545
Specialist visit (in-network) $285 $0 $0 $285 $285 $285
MRI (in-network) $1,025 $0 $819 (90%) $115 to reach deductible, plus $91 (10%) $115 $206
Three (3) formulary brand-name prescriptions filled at a network pharmacy $340 $0 $289 (85%) $51 (15%) N/A $51
Totals $3,520 $750 $1,878 $892 $1,500 $1,642
Maria's HSA balance at year end   $0        

Summary

  • By the end of 2018, Maria incurred $3,520 in medical and prescription drug expenses.
  • Maria used VMware's $750 HSA contribution to pay her doctor visits and an x-ray.
  • The plan paid $1,878.
  • Maria paid $892 out of her own pocket ($750 to meet the rest of her deductible + $142 for her share of specialist visit costs and prescription drugs).
  • She depleted her HSA, so there was no balance at the end of the year.

Maria's total cost for the year with the HSA PPO was $892. See below for how much Maria would have spent had she enrolled in the Traditional PPO plan.

How would this experience have differed under the Traditional PPO plan?

Here's a look at Maria's year if she had enrolled in the Traditional PPO plan:

Services Used Total Costs Amount paid by the plan Amount paid by Maria Amount applied toward the $500 individual deductible Amount applied toward the individual OOP maximum
Annual physical, lab tests, routine gynecological care exam (in-network) $770 $770
(100% covered preventive care)
$0 $0 $0
Three (3) doctor visits (in-network) $555 $495 $60 N/A $60
X-rays (in-network) $545 $40.50 $500 to meet the deductible + $4.50 (10%) $500 $504.50
Specialist visit (in-network) $285 $255 $30 copay N/A $30
MRI (in-network) $1,025 $922.50 (90%) $102.50 (10%) N/A $102.50
Three (3) formulary brand-name prescriptions filled at a network pharmacy $340 $255 (75%) $85 (25%) N/A $85
Totals $3,520 $2,738 $782 $500 $782

Maria’s total cost for the year would have been $2,926.40 under the Traditional PPO plan, which includes the total annual premium total of $2,144.40 ($89.35 per paycheck) plus her total out-of-pocket cost of $782. Under the HSA PPO plan, her total cost for the same services is only $892, or a difference of $2,034.40!

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