A Healthcare Headache

Reading Time: 4 minutes

I am extremely grateful for the many, many years we have had of employer-provided healthcare. We decided to look at the Pennsylvania healthcare exchange and find a plan that works for our family of 6 should we need to purchase our own coverage.

But I found myself staring blankly at the screen, trying to figure out which plan would provide for us without bankrupting us.

Image via Healthcare.gov

Seventeen plans showed up, listed by cost. Sounds straightforward, right?


The plans are listed by premiums only. The site has a tool to help you estimate expenditures of the deductible, copays, and other costs. The estimate is based on a loose calculation of whether each person’s use is low, medium, or high.

Accounting for the unexpected seems like a good idea for our family. We have four kids, one of whom was known by name to the ER doctors when we lived in Long Island.

I decided that I needed to look at the full deductible as well as the out-of-pocket maximum (OOP) to give me a better idea of the right plan. I also ran the numbers twice–once assuming medium use for everyone and once assuming high use by this child:

I made a spreadsheet and entered all pertinent information from the plans, sorted by premium fees. For comparative convenience, I used a yearly premium rate. The data on the main page listed premiums, estimated costs, deductible, and maximum out-of-pocket costs (OOP).

Within each data set, I color coordinated by cheapest/best option to most expensive/worst option and then italicized the higher 50% or so. It’s important to note that with the other (unspecified) fees the total you can spend is actually above the OOP number listed.

Full SPreadsheet
Full Spreadsheet

Looking only at the premiums and estimated costs can steer you in the wrong direction. While the $15 copay plan is the 4th cheapest by premiums ($949/month), if you have an emergency and have to cover the maximum costs you’re on the hook for $25,088. That makes it the 4th costliest by max OOP.

Fourth cheapest - or most expensive. Depends.
Fourth cheapest – or most expensive. Depends.

Let’s look at that first plan.

My estimated costs for the year with medium use are $12,996; with one child at high-use it’s $18,423. (It’s worth noting that with high use this plan is estimated to be my 4th cheapest option.) Here are the numbers we care about: the deductible is $9200, and the maximum OOP costs are $13,100.

That means that if anything crazy happens and we have a huge bill to cover, I not only need to have met that deductible, but I would be on the hook for almost $4,000 more. Looking at the coverage I see that I have low premiums, but high deductibles–and when you add up the total maximum possible cost of the plan, we’re at $22,292.

Lowest premium, not necessarily the cheapest option
Lowest premium, not necessarily the cheapest option

On this plan, you’re paying full price for everything until your deductible is met (other than an eye exam for children). What this plan has going for it, primarily, is a low premium–assuming you rarely get sick or injured, you could save a lot of money here. But it doesn’t look like the best bet for my family. If I’m going to have a high deductible, I want my max OOP to be within $2000 of that deductible. There are 12 plans with cheaper deductibles. Of those, three only differ by $1000-$2000.

I took the plans and sorted for deductibles. I then selected the plans with deductibles of $9200 and under and re-sorted by the difference between the deductible and the maximum costs. The 13th most expensive plan by premiums alone (Highmark · myBlue Access LP $1,500), pops up as my cheapest option.

The premiums are $4968 higher than the cheapest option, but the maximum cost is $3132 cheaper
The premiums are $4968 higher than the cheapest option, but the maximum cost is $3132 cheaper

This plan entails premiums of $1180/month, but the deductible is nice and low – $3000. The max I can spend out-of-pocket of $5000 for fees and co-pays after my deductible has been met. That brings me to an absolute total of $19,160 for the year. It’s part of a national network, qualifies for HSA, and once the deductible has been met the only costs are for prescriptions–generics $3, preferred brand $40, and non-preferred and specialty medications $90.

As a final experiment I plugged in myself as a high use patient–as the one who gets pregnant and therefore, would need to cover a lot more tests, I was curious to see what would happen. This time, only two plans ran under $20,000. And I was pleasantly surprised to see that the same $1180/month plan was estimated to cost $17,972–over the deductible, but still under the OOP.

Assuming I'm at high use for care, the estimate *dropped*
Assuming I’m at high use for care, the estimate *dropped*. Image via Healthcare.gov

If you need to get health care coverage in the exchange, first sit down and figure out how you use health insurance. Do you see the doctor often? Do you get a lot of lab work done? Do you use a lot of prescriptions? Will you be using inpatient or outpatient services? Don’t rely on premiums alone to guide you. Yes, it took two days of data entry and a lot of work to figure out the best plan for my family, but I’m confident in the plan I chose.