FSA, HSa, & Your Insurance
FSA & HSA
Both are accounts where people can put aside tax free money to help pay for out of pocket health expenses.
FSA – Flexible Spending Arrangement
FSA is provided by your employer and you do not need to have a health plan to qualify. However unspent money is lost at the end of the year.*
HSA- Health Savings Account
HSA is only available to you if you have a high deductible health plan (HDHP) and can be offered to you through many entities including banks, credit unions, employers, insurance companies, and more. The money does roll over at the end of the year.
FSA
Do not need to have HDHP
Your employer can contribute to it
You can contribute to it
Account is owned by your employer
Money does not roll over at the end of the year*
Money is lost if you leave the job
You must submit receipts to verify that the expense qualifies
HSA
You must be enrolled in an HDHP to qualify
Your employer can contribute to it
You can contribute to it
You own the account
Money rolls over at the end of the year
You keep the account when you leave an associated job
You do not need to submit records to qualify the expense but MUST save them
*Your employer may choose to either provide a 2.5 month grace period to use left over funds from FSA after the year is over OR allow you to roll over $500 into the following year.
Using FSA or HSA towards our practice:
Functional Packages:
You may use expenses from your provider visit, labs, other testing, and prescriptions that would otherwise qualify for your FSA or HSA plans. We can provide receipts and a superbill for these purposes.
DPC model:
You CANNOT at this time use your HSA for DPC membership fees. There is a possibility that joining a DPC would prevent you from continuing the HSA. This is because the IRS is categorizing DPC as a form of insurance. Other state (including Virginia) and federal agencies have clearly documented that DPC is NOT insurance. Requests thus far to correct this with the IRS have not been honored.
You may be able to use your FSA for DPC membership fees, but this would have to be determined by a tax specialist. You can use your FSA for labs, other testing, and prescriptions that would otherwise qualify.
insurance
Can you get reimbursed?
Functional Packages:
You may submit the visit for reimbursement if you have PPO. We can provide a superbill to you for this. HMO and EPO plans do not cover out of network providers at all. Many PPO plans will partially cover out-of-network providers but they will pay a smaller percentage of the visit than they would have for an in-network provider (if there is no out-of-network deductible to first exhaust) . However all of this depends on your policy, their rules, and is always subject to change.
DPC:
You cannot submit membership enrollment fees to insurance.
Labs, Tests, & Imaging:
You may use your insurance for these items. We will provide your insurance information (with your permission) to the lab or imaging center and they will charge your insurance. We can choose lab facilities and imaging centers that are in-network for you.
Amazingly, sometimes it’s cheaper to pay for the lab yourself than pay your percentage of the cost through insurance since there is unnecessary mark up on lab prices quoted to you. This is certainly the case if you have a high deductible and labs are not free for you. If you are paying out of pocket for labs with our discounted prices, you can submit receipts we provide to be applied for reimbursement and towards your deductible & out of pocket expenses (OOP). The insurance should honor this, though again we cannot confirm their policies for them.
Insurance terminology: what it means
Premium – The monthly amount you will pay for insurance coverage (for 2020 average unsubsidized individual cost $462/month; $784/month if ages of 55-64). Millions of middle income individuals/families who marginally do not qualify for subsidy are paying 4-5 times the subsidized ACA rate.
Deductible – what you have to pay out of pocket before insurance starts contributing (the average annual deductible for individual coverage in 2020 $4,604) from the Department of Human Health, CMS. This cost is less with higher monthly premiums, and greater with lower premiums.
Copayment – a fixed amount you pay for a service/medical cost; sometimes this is after the deductible has been met; plans vary
Coinsurance – The percentage of the medical cost that you must pay after you have paid your deductible in full.
Out of Pocket (OOP) limit – after you have paid your deductible in full, this is the amount you have to pay yourself before insurance starts paying full expenses. You will still have to pay your monthly premium even after the OOP limit is met. The Consumer Protection Act under ACA placed a cap on how high this limit can be ($8,200/individual in 2020).
So is it possible that you are paying more for health care because you have health insurance than cash customers are paying?
Actually, yes, according to health costs transparency companies. And you’re paying for a 10 minute rushed visit with a provider you never met before.
“Insured people have long thought their insurance policies grant them access to the negotiated or contract rate for an in-network provider, rather than the sticker price. At an out-of-network provider, a patient might need to pay the sticker price. But increasingly, we’re hearing that insured people are being asked to pay the sticker price — if they haven’t met their deductibles yet — for in-network providers.” (Jeanne Pinder 2019)
If you are responsible for paying the difference or a percentage, you should know the cost upfront.