Pros & Cons of common medical plan types

Get a sense for common medial plan types to assess which may be best for you and your employees. Look how these plans cover real-life scenarios and use the table below to compare different plan types.
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See how different plan types cover three real-life scenarios

Learn how these common plans types – copay only, traditional, and HDHP -- cover three real-life scenarios.

1. Having a baby

The average cost to welcome a child to the world is $13,540.

  • $3,900 with a traditional plan: The member is typically responsible for 20% of her medical costs up to the deductible ($2700)—and a percentage of the costs after that, including hospital charges for herself ($200 coinsurance) and the baby ($200 coinsurance), obstetric care ($200 coinsurance), and lab tests ($800 coinsurance). All of which totals $3,900 for a two-day stay.
  • $2,500 with a copay plan: With a copay plan there is no deductible, so the member will pay one charge for her entire hospital stay—about $2,500.

Net-net: The member fares better with a copay plan, in addition to knowing labor and delivery costs up front.

2. Making a sick visit to a primary care doctor

The average cost to visit a primary care doctor when your child has strep throat or an ear infection is $200.

  • $200 with a high deductible health plan (HDHP): The member will pay the full out-of-pocket price ($200), unless he's already met his deductible for the year. In 2018 HDHPs must have a minimum family deductible of $2600.1
  • $45 with a copay plan: With a straight copay plan the member would pay an average of $45 for an office visit copay.
  • $40 with a traditional plan: With a traditional plan the member would owe about 20% of the doctor's services, or $40.

Net-net: The member pays about the same with a co-pay or traditional plan, both of which cost less than the HDHP amount.

3. Visiting an emergency room

In an emergency you're probably not comparing costs, but a trip to the ER averages $6,600.

  • $2,760 with a traditional plan: You'll pay about $2,760 for services after you pay your deductible, plus coinsurance for the emergency room doctor, X-rays and lab tests, among other things.
  • $1,200 with a co-pay plan: You'll owe about $1,200 for everything, including straight copays for the ambulance, ER and any advanced imaging.

Net-net: You'd fare better with a co-pay plan, even with unexpected medical issues.

Disclaimer: These examples are for illustrative purposes only. Services based on average costs and average copays (what you pay) if you use in-network providers. Actual costs for medical services will vary by plan and geography.

Common Medical Plan Types

Plan name High Deductible Health Plan (HDHP) Traditional plan (Copy + Deductible plan) Copay only plan This plan is best for a business with…

…many single and/or healthy employees with low healthcare use.

…employees who want flexibility to receive care from in-or out-of-network doctors or hospitals.

…employees with regular healthcare needs, because there’s no deductible to meet before insurance kicks in when in-network providers are used.

This type of plan…

…offers a lower monthly premium in exchange for a higher deductible.

…helps pay doctor bills, lab tests and prescriptions from the first day.

…lets member know the upfront costs for medical services, from specialist office visits to having a baby.

Be aware

The lower upfront cost means employees pay for medical services until they meet the (high) deductible and insurance kicks in.

For 2018, these plans must have a minimum deductible of $1300/single and $2600/family.1

Generally, the insurer pays 80% of the cost for medical services and the member is responsible for the rest, plus the copay.

Copayments continue, even after the deductible is met.

A deductible typically applies when out-of-network doctors and facilities provide medical services.

Ways to drive down cost

Pair with a Health Savings Account (HSA) so employees can contribute pre-tax dollars to help pay for healthcare expenses now, and in the future.

  • Funds are employee-owned for life
  • Funds earn tax-free interest, and build from year to year

Employees can pay less for care by choosing in-network providers.

Reduce premium costs by opting for a “narrow network” which has a smaller group of medical providers, and often relies on a primary care physician to direct care.

Out of area coverage can be limited, so this is best for a workforce who works at a single location.

 

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