I’ve been trying to get better educated on high deductible health plans, and my googling on a specific question wasn’t fruitful so I thought I might come to the dope (long time lurker, infrequent poster).
Since it’s the beginning of the year, I always get excited about paying full price for my insulin prescriptions, anxious about getting the deductible paid. For those outside the US, an HDHP has me paying full price for health coverage until the deductible is met ($2,800 this year), and after that my insurance will pay 100%.
I was in CVS last week, my HSA debit card in hand with a balance of $2,800 available. My 4-week supply of insulin rang up at $95 – more than the $0 it cost last month, but it seemed way too cheap.
I checked my insurance plan online today and it shows $818.40 applied towards my deductible.
Is there some reason my health insurance carrier gives me more credit towards my deductible than I actually paid at the pharmacy counter? I’m not complaining – and to be quite honest, I am reluctant the call my health insurance to ask why, since – if it’s not correct – the “fix” would cost me money. I feel like I landed on Chance and got “bank error in your favor: collect $723.40”.
If there is no error, I feel like I have a fundamental misunderstanding of how HDHPs work – and I welcome any information the dope may provide.
That’s certainly not the way mine works. Is it possible that you were looking at an Explanation of Benefits and that was the “Discounted amount - You’re not responsible for this” column?
Hard to answer from your description, but to address other points:
Are you certain the health insurance’s fiscal year matches up to the calendar year? Mine is July-June.
Are you certain insurance pays 100% after the deductible is met? Usually there is a second higher limit that is the out-of-pocket maximum. Additionally, preventative care may not cost you anything.
If you have a real HSA where the money can stay in there indefinitely, and not a health FSA where the money goes away at the end of the year, consider not using it. HSAs are a neat little thing where you can take the money out at any time (today or in 30 years) and there is no penalty as long as you use it for healthcare. The trick is that you can also spend it on health purchases you made 30 years ago. So keep records of health expenses, use your regular bank account as long as you can afford this, and then use the HSA on a rainy day, matching up to any valid past medical expenses. You can also often invest HSA money, and can keep it even if you leave your employer.
Call your insurance and have them explain it. If it were indeed an error, they will catch it later anyway. Not quite the same thing as spending an erroneous deposit in your checking, but it will likely not work out in your favor.
Thanks for the replies so far.
thelurkinghorror – Re: #3, I’ll definitely consider saving HSA funds in the future - right now I’m keeping that money “saved” in case it does end up an error that I can resolve by paying what I owe out of the HSA.
The out-of-pocket is the same amount as the deductible for my plan – and I am definitely looking at the “deductible” on my health insurance website. “Family Deductible: $818.40 applied towards $2800 limit”. Another screen shows “Amount remaining: $1981.60”.
One other data point, I had this plan last year and I noticed this then, but it was a new job and my first time in an HDHP, and I was slightly less curious, just glad when everything was free. My HSA lets me log in and see every transaction, as does my health insurance carrier. Last year the “patient responsibility” column of transactions exactly totals $2700. Not a single transaction amount from my HSA debit card marches the “patient responsibility” (and amount credited towards my HD). 2/19/19 for instance I paid $140.52. The patient responsibility on the claim list for that day shows $638.84. That was the tipping point, and I didn’t pay a penny more towards prescriptions (or other health expenses) that year.
I’m a bit relieved that my expectation of dollar-for-dollar credit of amounts paid versus credit towards deductible seems correct. I suppose I’ll give them a call at some point to see what’s going on …
I think this is the root of the problem. The company will eventually get it right, exactly the same way as
turns into the back collecting their $723.40 back a little while later, so you better not spend it.
Of course, it could be CVS who messed up and they should have charged you $818 for your 4 weeks of insulin*, but only charged you $95. In which case, it’s CVS who may be coming to you for more money, or eating the loss.
*Going on the record to say the phrase “they should have charged you $818 for your 4 weeks of insulin” is one of the worst things I have ever typed.
Agreed. It is interesting to me that, in my experience, HDHPs are often “marketed” to people with very low health costs – they are encouraged to shop around for good prices since it’s out of pocket, even hinting that these plans help make health care costs more susceptible to market forces and customer price shopping. For me it’s the exact opposite - I don’t care if I go through my deductible by mid February or late March – I’m still spending the same amount on health care costs this year.
It also occurred to me that CVS appears to be charging me one thing, and submitting the claim to my insurance for a different amount …maybe charging me their “uninsured cash-pay” price, but the claim is the with-insurance price…and there’s nowhere on the information exchange for them to tell my insurance how much was actually paid.
If I get an answer from my insurance I’ll report back (assuming anyone but me is interested in this).
Did you get some sort of coupon applied from your insulin’s manufacturer?
I had a coupon from E. Lilly for my Trulicity, which amounted to like $250 off. The cost of the meds was $750 or so. I gave the coupon to my pharmacy who added it to my account at the pharmacy. When they ring it up, I pay $500 but the full $750 was still applied to my deductible.
The coupon was not so much a coupon as a…subscription card? I had to sign up for it on the Trulicity web site and E. Lilly decided how much of a discount I was able to get and stuff. And it worked all year for my prescription. I only had to give it to the pharmacy once, though, same as when I gave them my insurance card.
Anyway, I’m wondering if you signed up for such a thing and don’t remember. Or CVS applied it for you (they got it possibly through GoodRX or through the manufacturer of your insulin.)
Don’t press your insurance too hard on the issue. I always felt like I was “scamming” the insurance doing this but of course I wasn’t. I was getting scammed several ways lol
I think you may be correct. I haven’t spoken with CVS to confirm, but the health insurance rep said he’s seen this before – CVS is likely applying some coupon or discount that I’m not aware of but apparently qualify for. Sounds like it’s entirely behind the scenes from my perspective, but the rep said that that they do get the full “patient responsibility” amount, just part of it comes from a 3rd party “coupon” via CVS. I’ll ask CVS next time I’m there…
The insurance is quick acting – humalog insulin pen (“kwikpen”). I’ve never seen it for cheap, but I might not be looking in all the right places (and with my HDHP I have no incentive to look). My long acting Basaglar is similarly expensive.
I’ve seen this happen once or twice , where I go to an out-of-network doctor- the “bill” to the insurance company is $200, doctor is out of network* so the insurance is not going to pay and I actually pay the self-pay price of $70. I get credit toward my deductible for $200 because that’s the only number the insurance company has.
I still ask the dr to process the claim because I want to get credit toward the deductible.
Is it possible that your insurer is taking part in the HSA Expansion, one benefit of which is that insurers can cover the costs of certain drugs - insulin included - before the deductible is met?
As an aside - my insurance is very similar to yours, I pay 100% until I meet the deductible and then everything is covered 100%. I’m always pushing to get through that #@ deductible so I can quit carrying around my HSA card. As a T1 diabetic, that’s not too hard. That first prescription of insulin gets pretty damn close - last time the total cost was $1740.00. Always fun times.
It used to be fairly cheap. However, prices for most common forms have roughly tripled over the past decade, after big increases in the decade before that.
Human insulin (which is metabolized differently from the analog form now in most prescription insulin) is still available over-the-counter fairly cheaply, but not everyone can take that form.
My HDP plan bills prescriptions separately from other medical care. I pay a copay, ranging from $4 to about $12, monthly for each of my 3 prescriptions even if I haven’t met the deductible. However, in 2017 and 2018, when I did meet the deductible due to cancer treatment, after meeting the deductible, I had zero copays.
Thanks again for rhe replies. I won’t be back to the pharmacy in a while, but for the moment I’m satisfied that there is likely no funny business going on that I’ll be asked to repay later. I don’t think this is part of the HSA Expansion, because my deductible is being paid down – it’s not that the insulin is being paid for before the deductible is met.
I might pop back in in a month or so if I have more info.
It also occurred to me that if this is a behind-the-scenes coupon situation, and I can pay $100 for $800 credit to my deductible, it’s in my economic interest to pay towards my deductible at CVS for insulin BEFORE I do any labwork or doctor’s visits, since it’s unlikely I’d be eligible for a similar discount for those services. This is likely to happen anyhow, but this appears to be another weird side effect of the dumb US health insurance systems – I have an incentive to delay treatment until I meet my deductible at CVS. I wouldn’t do so, but might someone walk around on a broken ankle for a month while they’re meeting a $2800 deductive for $400, since a January 1 ER visit and other broken ankle services could cost them $2,400 since there’s no coupon for those services?
When there’s a coupon involved the original charge amount is a positive charge, then the coupon is applied later as a negative amount. The original positive charge will always be sent to the health insurance company and added to your deductible. What happens next with coupon next depends on the health insurance company and what that particular group wants. Sometimes you get to keep the difference. Sometimes it’s removed from your deductible, either immediately as an automated process or manually by an adjuster when they get around to it. If may take a few weeks to be able to confirm that there’s been a “bank error in your favor” as you insurance, if it’s done manually, might not have entered the negative value yet.
It has been noticed that you could game the system that way, Go get a bunch of RX prescriptions that load up your deductible but that you only actually paid a fraction of that for and then go and get medical services. That’s why companies are starting to have the deductible reflect what the subscriber actually paid, not what the list price was.
It is interesting to me that, in my experience, HDHPs are often “marketed” to people with very low health costs – they are encouraged to shop around for good prices since it’s out of pocket, even hinting that these plans help make health care costs more susceptible to market forces and customer price shopping. For me it’s the exact opposite - I don’t care if I go through my deductible by mid February or late March – I’m still spending the same amount on health care costs this year.