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Deductibles Individual or Aggregate?

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Question: There are 2 members in my family, a 59 y/o and an 18 y/o out-of-state college student. We are looking at the BS Silver 70 PPO plan. If one of us is hospitalized, is the deductible $2,000 (individual) before the 20% starts or would it be $4,000 since we are a family? Likewise, is the same true for maximum out-of-pocket expense? If it is the $4,000, it seems wiser to go with the Gold 80 plan at $100 more per month rather than risk the deductible. Your thoughts?

Answer: Nearly all of the ACA-compliant individual plans (the only plans you can buy now), have individual deductibles. So in your example (if one of us is hospitalized...) once the $2,000 deductible is met the 20% coinsurance goes into effect. The Bronze HSA plan is the only plan in the new portfolio where the deductible is collective or aggregate, meaning the family deductible of $10,000 would have to be met before the 20% coinsurance goes into effect. The out-of-pocket maximum is individual as well. Also, the Blue Shield PPO is the only Covered California qualified plan that will cover your college student "in-network" while out-of-state.

7 Comments

No reason they should make this simple to understand.

As I’ve stated in this thread, our BRONZE plan calls it a MEDICAL DEDUCTIBLE (you can see the quotation directly from our policy in one of my comments below). However, it acts as you said: it’s the amount of first-dollar expenses that must be paid before any cost-sharing applies.

Also, our HSA plan, unfortunately, requires the entire family deductible to be met before one person can begin collecting benefits. I think that’s outrageous, especially since it is not disclosed anywhere (unless and until you can get a copy of the policy itself).

But thank you for clearly stating a difference between BRONZE and SILVER plan deductibles that I was not aware of — that’s a pretty huge difference.

“Nearly all of the ACA-compliant individual plans (the only plans you can buy now), have individual deductibles.”

Beware of this statement. There are two types of deductibles, only one of which applies to a particular plan.

“Individual Deductible” == applies to all BRONZE plans, and is the amount of first-dollar expenses of all types that the insured must pay BEFORE any cost-sharing (copays or coinsurance) applies. In most BRONZE plans, this is $5000. Most Bronze plans also permit up to three physician office visits without applying the deductible. Most HSA plans limit the individual deductible for one person to $4500, and $9000 for a family.

On the other hand, SILVER plans have a “MEDICAL DEDUCTIBLE” (not an “individual deductible”) which does NOT apply to most first-dollar expenses, but does apply to more costly diagnostic radiology (CT, MRI, PET) procedures, ER, and inpatient hospitalization. There is a medical deductible for each person in the household, limited to up to $2000 per person and $4000 per household (four persons in a single household could collectively aggregate $2000 in medical deductibles, and all could still be exposed to another $2000 in “Medical” expensees).

The “OUT OF POCKET” maximum under both BRONZE and SILVER plans is $6350 for one insured, and $12,700 for a household of 2 or more.

Back to the original question. I wanted the BS Gold 80 plan for the exact reason (only 100 more a month with no ded) are you saying that it is not available even tho it is listed on the website. My agent signed me up for silver 70 and I thought he told me the other one was not available. I thought I was making a mistake in what plan I was asking for. I researched and I see gold 80 available with the info I put in. I have an email into him, I would really like the gold 80 ( 2 person house old with $57k income). thank you

As a followup in case anyone else reads these comments, I’ve since learned that the Blue Cross Bronze HSA plan is exactly as Darcy stated.

So in this case, there is a HUGE difference between the BC & the BS Bronze HSA plans, yet no way for the consumer to be able to learn of this difference unless they explicitly call both providers and ask.

Under the worst-case scenario, the BS plan could actually have out-of-pocket expenses for one person under a family plan of $31,400 (in-network and out-of-network), compared to $13,500 for the BC plan, a difference of almost $18,000!

Darcy, that’s exactly right: There is no indication that the answer is correct — but it is.

At least, it is correct for the BS Bronze HSA. I was finally able to get the text of the actual plan, not the summary that is readily available. There it is spelled out in clear English:

“The individual Medical Deductible applies when an individual is covered by the plan. The Family Medical Deductible applies when a Family is covered by the plan, and the entire Family Medical Deductible must be met before Blue Shield begins payment for Covered Services for any Member with Family coverage.”

The same is repeated for the out-of-pocket maximum. So if one person needs medical treatment under this plan, they can expect to pay up to $12,700 out-of-pocket during a calendar year for in-network services (it goes up to $18,700 for out-of-network).

My understanding of the Bronze HSA plans is as follows:

The individual deductible is $4,500 (not $5,000). The family deductible is $9,000. After one person reaches their $4,500 deductible, then they pay 40% with an out of pocket maximum of $6,350.

I see no indication that what you say is correct.

Do ALL Bronze HSA plans use aggregate deductibles?! How were we to determine this? There is no wording in the description of the policies that shows this. All the plans seem to be the same (they show individual and family limits, but never state that some plans require an aggregate for families). Am I missing or mis-understanding something? (We have the BS Bronze HSA plan and we thought we had individual deductibles and out-of-pocket limits.)

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