How to Choose a Medical Plan

Here's how one woman navigated the choices in the University's health plans.

Maria, age 29, is a computer programmer earning $70,000 a year. She’s expecting a baby in June. She sees an in-network obstetrician who has admitting privileges at New York Presbyterian Hospital. After Maria’s in-network obstetrician confirmed the pregnancy, she made appointments to return monthly until Week 36 of her pregnancy, when appointments become weekly. According to her doctor, Maria should expect to have two sonograms at an outpatient testing center and various tests, such as blood and glucose screenings, throughout her pregnancy, plus a 48-hour hospital stay for a vaginal birth, with professional services and tests. She’s already started taking prescribed prenatal vitamins.

Currently, Maria and her husband are enrolled in the Choice Plus 80 plan. Maria contributes to a Healthcare Flexible Spending Account. She is considering changing to the High Deductible Health Plan (HDHP) during Open Enrollment.

The Choice Plus 80, 90 and 100 plans cover preventive care, primary care physician office visits and preventive prescription drugs at the same level—100% or copays for office visits and prescriptions. The plans differ in coverage of laboratory tests, outpatient radiology (like X-rays), and outpatient or in-patient hospital procedures. Deductibles that vary with each plan apply to each family member, followed by coinsurance in the Choice Plus 80 and 90 plans, and copays in the Choice Plus 100 plan.

Maria's Costs:

By the time Maria’s baby is expected at the end of June, Maria will have six months of monthly medical contributions at the Yourself & Spouse level, plus six months at the Family level.

Annual Contributions*

Plan: HDHP
Contribution: $1,800

Plan: Choice Plus 80 Plan
Contribution: $3,768

Plan: Choice Plus 90 Plan
Contribution: $5,298

Plan: Choice Plus 100 Plan
Contribution: $13,692

_{*Calculations based on salary tier and 2022 monthly medical contributions for full-time Officers.}

Service: Prenatal office visits
Billed by Provider: N/A
Notes: Maria is responsible for one copay for the first visit to confirm pregnancy. Subsequent visits are included in final obstetrician bill (see Delivery).
Paid by Maria: $30

Service: Prenatal vitamins
(prescription)
Billed by Provider: N/A
Notes: Maria is responsible for the copay each time the prescription is filled.
Paid by Maria: $25

Service: Sonagram 1
Billed by Provider: $600
Notes: In-network outpatient facility bill. This is Maria’s first non-preventive service of the year, so she needs to meet the $600 deductible before the Plan covers services.
Paid by Maria: $600

Service: Lab work 1
Billed by Provider: $600
Notes: In-network lab bill. In the Choice Plus 80 plan, after the deductible is met the Plan pays 80% and the member pays 20%. Maria is responsible for coinsurance of $120.
Paid by Maria: $120

Service: Sonagram 2
Billed by Provider: $600
Notes: In-network outpatient facility bill. Maria is responsible for coinsurance.
Paid by Maria: $120

Service: Lab work 2
Billed by Provider: $600
Notes: In-network lab bill. Maria is responsible for coinsurance.
Paid by Maria: $120

Service: Two-day hospital stay
Billed by Provider: $21,000
Notes: Hospital bill for vaginal birth and newborn care. 20% is $4,200, but coinsurance only applies until the individual, in-network, out-of-pocket maximum of $3,750 is met. After, the Plan picks up the costs. So far, Maria has paid $1,015 out-of-pocket towards in-network services so she is responsible for $2,735.
Paid by Maria: $2,735

Service: Delivery
Billed by Provider: $3,000
Notes: Obstetrician bill. Since the out-of-pocket maximum was met, Maria was not responsible for coinsurance.
Paid by Maria: $0

Service
Billed by Provider
Notes: Maria’s Total Out-of-Pocket Costs:
Paid by Maria: $3,750

Service: Prenatal office visits
Billed by Provider: N/A
Notes: Maria is responsible for one copay for the first visit to confirm pregnancy. Subsequent visits are included in final obstetrician bill (see Delivery).
Paid by Maria: $30

Service: Prenatal vitamins (prescription)
Billed by Provider: N/A
Notes: Maria is responsible for the copay each time the prescription is filled.
Paid by Maria: $25

Service: Sonogram 1
Billed by Provider: $600
Notes: In-network outpatient facility bill. This is Maria’s first non-preventive service of the year, so she needs to meet the $400 deductible before the Plan covers services. Coinsurance applies to the remaining $200. In the Choice Plus 90 plan, the Plan pays 90% and the member pays 10%. In this case, Maria was responsible for coinsurance of $20, plus the deductible.
Paid by Maria: $420

Service: Lab work 1
Billed by Provider: $600
Notes: Maria is responsible for coinsurance.
Paid by Maria: $60

Service: Sonogram 2
Billed by Provider: $600
Notes: In-network outpatient facility bill. Maria is responsible for coinsurance.
Paid by Maria: $60

Service: Lab work 2
Billed by Provider: $600
Notes: Maria is responsible for coinsurance.
Paid by Maria: $60

Service: Two-day hospital stay
Billed by Provider: $21,000
Notes: Hospital bill for vaginal birth and newborn care. 10% is $2,100, but coinsurance only applies until the individual, in-network, out-of-pocket maximum of $3,250 is met. After, the Plan picks up the costs. So far, Maria has paid $655 out-of-pocket towards in-network services so she is responsible for $2,100.
Paid by Maria: $2,100

Service: Delivery
Billed by Provider: $3,000
Notes: Obstetrician bill. Maria is responsible for coinsurance.
Paid by Maria: $300

Service
Billed by Provider
Notes: Maria’s Total Out-of-Pocket Costs:
Paid by Maria: $3,055

Service: Prenatal office visits
Billed by Provider: N/A
Notes: Maria is responsible for one copay for the first visit to confirm pregnancy. Subsequent visits are included in final obstetrician bill (see Delivery).
Paid by Maria: $30

Service: Prenatal vitamins (prescription)
Billed by Provider: N/A
Notes: Maria is responsible for the copay each time the prescription is filled.
Paid by Maria: $25

Service: Sonogram 1
Billed by Provider: $600
Notes: In-network outpatient facility bill. This is Maria’s first non-preventive service of the year, so she needs to meet the $200 deductible before the Plan covers services. In the Choice Plus 100 plan, after the deductible is met the Plan pays 100% and the member pays 0%.
Paid by Maria: $200

Service: Lab work 1
Billed by Provider: $600
Notes: In-network lab bill. Paid by the Plan at 100% since Maria met the deductible.
Paid by Maria: $0

Service: Sonogram 2
Billed by Provider: $600
Notes: In-network outpatient facility bill. Paid by the Plan at 100% since Maria met the deductible.
Paid by Maria: $0

Service: Lab work 2
Billed by Provider: $600
Notes: In-network lab bill. Paid by the Plan at 100% since Maria met the deductible.
Paid by Maria: $0

Service: Two-day hospital stay
Billed by Provider: $21,000
Notes: Hospital bill for vaginal birth and newborn care. Since the deductible was met, Maria is only responsible for the $500 hospital copay.
Paid by Maria: $500

Service: Delivery
Billed by Provider: $3000
Notes: Paid by the Plan at 100% since Maria met the deductible.
Paid by Maria: $0

Service
Billed by Provider
Notes: Maria’s Total Out-of-Pocket Costs:
Paid by Maria: $755

The High Deductible Health Plan applies the $3,000 family deductible to the contracted costs of the non-preventive visits and the non-preventive drugs. After the deductible is met the Plan begins to pay 90% of covered in-network services.

Service: Prenatal office visits
Billed by Provider: $2,100
Notes: Maria needs to meet the $3,000 deductible before the Plan covers services, so she is responsible for the full amount billed.
Paid by Maria: $2,100

Service: Prenatal vitamins (prescription)
Billed by Provider: N/A
Notes: Maria is responsible for the copay each time the prescription is filled.
Paid by Maria: $25

Service: Sonogram 1
Billed by Provider: $600
Notes: In-network outpatient facility bill. Maria needs to meet the $3,000 deductible before the Plan covers services. She's only paid $2,100 so far so she is responsible for the full amount billed.
Paid by Maria: $600

Service: Lab work 1
Billed by Provider: $600
Notes: In-network lab bill. Maria needs to meet the $3,000 deductible. She's only paid $2,700 so far so she is responsible for $300. Coinsurance of 10% applies to the remaining amount, $300. In this case, Maria was responsible for coinsurance of $30, plus the deductible.
Paid by Maria: $330

Service: Sonogram 2
Billed by Provider: $600
Notes: In-network outpatient facility bill. Maria is responsible 10% coinsurance.
Paid by Maria: $60

Service: Lab work 2
Billed by Provider: $600
Notes: In-network lab bill. Maria is responsible 10% coinsurance.
Paid by Maria: $60

Service: Two-day hospital stay
Billed by Provider: $21,000
Notes: Hospital bill for vaginal birth and newborn care. Since the deductible was met, 10% coinsurance is applied until Maria’s out-of-pocket total reaches $7,100. So far, Maria has paid $3,175 out-of-pocket towards in-network services so she is responsible for $2,100.
Paid by Maria: $2,100

Service: Delivery
Billed by Provider: $3,000
Notes: Obstetrician bill. Maria is responsible for coinsurance.
Paid by Maria: $300

Service
Billed by Provider
Notes: Maria's Total Out-of-Pocket Costs
Paid by Maria: $5,575

Maria's husband is in excellent health. His costs are expected to be minimal, limited to preventive care. Maria added annual medical plan contributions to expected out-of-network costs of the pregnancy and birth to narrow her choices to the HDHP and the Choice Plus 80 plans.

Plan: HDHP
Contributions (annual)*: $1,800
Expected Out-of-Pocket Costs (annual): $5,575
Total: $7,375

Plan: Choice Plus 80
Contributions (annual)*: $3,768
Expected Out-of-Pocket Costs (annual): $3,750
Total: $7,518

Plan: Choice Plus 90
Contributions (annual)*: $5,298
Expected Out-of-Pocket Costs (annual): $3,055
Total: $8,353

Plan: Choice Plus 100
Contributions (annual)*: $13,692
Expected Out-of-Pocket Costs (annual): $755
Total: $14,447

Because the expected cost differences were so close, Maria had a difficult time deciding which plan to choose. The relatively-low monthly contributions of the HDHP appealed, as did the possibility of having a Health Savings Account (HSA)—which would allow her to put aside pre-tax dollars to pay for health expenses, and keep the full account balance when the year is over—something possible only under the HDHP. But Maria was a bit concerned that if something unexpected happened early in the year she would have to pay the $3,000 deductible before she'd built up her HSA savings.

Ultimately, Maria decided to enroll in the HDHP and contribute the $7,300 maximum for 2022 ($7,200 for 2021) to an HSA. She feels confident she could work out a payment plan with any provider. She plans to review her options again next year.

_{*Calculations based on salary tier and 2022 monthly medical contributions for full-time Officers.}

How to Choose a Medical Plan

Maria’s Medical Plan Contributions

Annual Contributions*

How the Choice Plus 80 plan Would Cover It

Maria’s Total Out-of-Pocket Costs:

$3,750

How the Choice Plus 90 plan Would Cover It

Maria’s Total Out-of-Pocket Costs:

$3,055

How the Choice Plus 100 plan Would Cover It

Maria’s Total Out-of-Pocket Costs:

$755

How the HDHP Would Cover It

Maria's Total Out-of-Pocket Costs

$5,575

What Maria Chose

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