High or Low Deductible Health Insurance? HSA or FSA?

Employer Health Insurance Basics

One thing many early career academics (or those moving internationally to the U.S.) have little experience with is a choice between different kinds of health insurance plans. Here are some basics to get you oriented.

Broadly speaking, health insurance comes in two major flavors: low-deductible plans with a flexible spending account (FSA), and high-deductible plans with a health savings account (HSA). Here’s what those things mean:

  • Deductible: The amount you spend out of pocket on covered expenses before the insurance plans starts paying for (non-preventive) health care. (Just because a plan is ‘high deductible’ doesn’t mean that it’s all that high. For instance, mine is $1600 for an individual, which is easy to hit.)
  • In FSAs and HSAs, your employer may or may not contribute to it for you, and there is an individual contribution limit. Your contributions are pre-tax, meaning that you substantially save money by contributing to these accounts.
  • In FSAs, you need to spend the money by the end of the year, perhaps with a short grace period.
  • In HSAs, your money can carryover indefinitely, you can withdraw funds to cover healthcare expenses from far in the past whenever you want, you can invest the money in index funds and money markets, and if you withdraw funds to spend on health care costs, those dollars will never be taxed. For this reason, many personal finance gurus recommend you use your HSA as a tax-advantaged retirement account.

How to Choose between Plans

That wasn’t too bad, right? But what should you do? Here’s how I suggest you approach which to choose if you have a decision:

  • Most employers that offer a choice will offer a quiz to advise you on which is better for you. That’s not a bad way to decide if you’re not sure.
  • But part of this comes down to situation and psychology. If you don’t have the financial reserves to handle an unexpected $1000 medical expense, or you find that prospect stressful, you may prefer the low-deductible option even if it doesn’t strictly make the most financial sense. (You can usually change your enrollments from year to year if you change your mind or circumstances change.)
  • As a tiebreaker, remember that you can use HSAs as a 100% tax-free retirement investment savings vehicle. It’s the only retirement account you can get on which you likely will never pay taxes, which is a huge win.

You should also remember that you may be eligible for plans besides those sponsored by your employer. Perhaps a family member has a plan for which you are eligible. You may be eligible for Obamacare marketplace plans, or even Medicaid. To fully review your options, I recommend gathering the following information into one spreadsheet or notepad:

  1. Monthly premiums: This is how much you pay monthly out of pocket to be part of the plan. (Note, these payments are tax-deductible.)
  2. Deductible: This is how much you have to pay out of pocket before your insurance benefits kick in for non-preventive care.
  3. In network out of pocket max: This is the most you will pay out of pocket in a year for covered medical care. (Note there are often exceptions for care with capped lifetime or annual coverage, such as for assisted reproductive services. Any expenditures beyond these covered caps are entirely your responsibility regardless of your out of pocket max.)
  4. Co-pays on covered visits, procedures, and generic pharmaceuticals: This is how much you’ll pay for services that are covered by your insurance (often after your deductible).
  5. Other notable coverage that you anticipate needing. For instance if you’re pregnant or want to be, you should obviously check out coverage for pregnancy, delivery, and postnatal care.

I’ve put together several fairly exhaustive spreadsheets since I joined my current university. Every way I’ve looked at it at my current employer, the high deductible plan has been financially better for me (usually by a couple hundred dollars per year), even without accounting for the benefits of HSAs. However, the devil is often in the details, so be sure to study your plans’ details carefully, and be sure to use your university’s resources to the max to make an informed decision.

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