Calendar year changes and Out-of-Pocket reset

Question

I have been with a School District for three years.

This last year I had major surgery. I met my deductible and by August I reached my OOP max. In September the district got a new plan. They made arrangements to reimburse employees for deductibles that were more than the original Jan to Dec. plan amount. They did not make the same arrangement for the OOP. So in August I owed no co-pays. September first I owe 30.00 co-pays.

If I was on a plan, and paid for a plan that is on a Jan to Dec cycle, how can they disregard what I have been paying for all year and reset me back to zero; when I technically have 4 more months on the calendar year agreement?

If they keep changing the plans mid year, why are employees on a calendar year. The OOP and the deductible amounts are really of little consequence when they reset everything within 8 months rather than 12. Is this legal?

Answer 1

Yes, it's legal, and I know it feels unfair. My guess is that the district thought it made more sense to start and end the plan year in September with the school year, and when they changed plans (everyone's plan is changing due to Obamacare), they had an opportunity to change it.

It's unfortunate that you have to start paying co-pays again 4 months early, but it could be worse. It is generous of the district to cover your deductible, which they are not required to do.

Up until last year, our company's medical plan began July 1. At the end of last year, we were forced to restart the plan January 1 to meet some Obamacare requirements. I had just (in December) met the deductible of my High Deductible Health Plan, so this move cost me thousands.

Now that your district's health plan is lined up with the school year and hopefully meeting the new requirements, I would say it is unlikely that they will switch mid-year again, especially if they are reimbursing employees for deductibles.

Answer 2

Talk to HR for the school district, or your Union if you have one. If the switch was before the originally announced 12 month period expired, they could have negotiated with the new company how to handle the deductible and out-of-pocket limits. The bigger the employer the more power they have to set the guidelines regarding these values. It is possible that they didn't send the information and balances to the new plan.

If this is the normal time they make the change in plan year, then you are out of luck.

I had this happen when the insurance company accidentally reset the balances on 1 January when we had a July to July policy year. It was quickly resolved.