Can we use a QLE to lower OOP max with a better plan?

Plan Benefits Forum
1

Here’s some background: We chose the Value plan for my wife and me, with an individual deductible of $4,000 and an OOP max of $7,000. The family deductible is $8,000, and the family OOP max is $14,000.

We recently welcomed a baby in September, and I’m considering upgrading to the Premium plan to lower our OOP max for the family.

My wife’s OOP was $4,000 before the delivery, and she’ll definitely hit her OOP after the delivery.

Here are my questions:

  1. Can I switch to the Premium plan after applying for a QLE (qualifying life event) and get access to the $8,000 family OOP max?

  2. If I can switch, how do they calculate the OOP for the Value plan until September and then the Premium plan from September to December? Will the OOP max be prorated, or will it reset under the new plan?

Both plans are under the same insurer and provider.

I’m trying to figure this out to save some money. Any advice is appreciated.

2

Thanks for posting! Just a reminder, if you have a medical emergency, call 911. Including your age, state, and income helps people give better advice. Having your EOB handy is helpful too.

3

If you switch plans, especially if it’s through the marketplace or a small employer, you’ll lose all your spending progress, and the plan will reset as if it started the month of the QLE. Some employers won’t let you change for that reason, or if they’re self-insured, they may have their own rules.

4

@Wylie
I have a PPO plan with the same OOP max for Value, Premium, and HSA plans. I’m thinking about switching to the HSA plan to at least get the $1,000 employer match that I could use to cover my OOP max. My employer allows plan changes due to a QLE.

5

@Emerson
A few things:

  1. The IRS limits how much you can contribute to an HSA based on how long you’ve had the plan in a year. Since you’d be starting in September or October, your contribution limit will be prorated, so the $1,000 match might be reduced.

  2. HSAs often use aggregate deductibles, meaning the family deductible applies to everyone, not just individual deductibles like PPOs.

  3. The out-of-pocket max for HSAs is capped federally, so it might be around $7,900 per person even if your plan’s family OOP max is higher.

6

@Wylie
Thanks! That’s super helpful. Now I’m thinking of switching to the Premium plan from October to December, then going back to Value after. It’ll cost $900 more in premiums, but the family deductible would be $2,000, or $1,000 per person. The main savings would be from the 10% difference in copays (30% on Value vs 20% on Premium). If my baby’s medical bills after birth exceed $10,000 from September to December, it might make sense to switch. Am I thinking about this correctly? Any suggestions? I’ve decided against the HSA and plan to contribute to an FSA instead to save on taxes.

7

QLEs usually have specific rules about what changes you can make. You might not be able to switch plans unless your current plan doesn’t support your QLE.

8

Masitsa said:
QLEs usually have specific rules about what changes you can make. You might not be able to switch plans unless your current plan doesn’t support your QLE.

According to my employer, I can switch between HSA, Value, and Premium plans due to a QLE.