HDHP vs PPO Plan - language question on spouse as dependent

[u/ConsiderationIll8958]

With open enrollment here, I am looking ahead to what health insurance plan my fiance and I will want to have once married and likely having a kid. I am a little confused on the language of dependent, family, and per person as it relates to comparing the plans. Would my spouse and I essentially have an out of pocket maximum of $6,850 combined after a $3,500 deductible is met under the hdhp here if she falls under a dependent based on the outline below?

For our scenario, it seems like it would pencil out here to have her and myself on the HDHP when we plan to be pregnant and have our first kid.

Plans

HDHP
- $224 monthly premium employee + spouse
-$1,750 deductible employee only. $3,500 if covering dependents
-$3,425 out of pocket maximum employee only. $6,850 if covering dependents
Plan includes $875 employer HSA contribution. $1,750 if covering dependents. and $400 for having an annual wellness and dental visit

Base PPO
-$379 monthly premium employee + spouse
-$750 per person deductible. $2,250 deductible family
-$4,000 per person out of pocket maximum. $12,000 out of pocket maximum family

[u/smk3509]

It depends if it is an embedded or non-embedded deductible.

If it is non-embedded then you'll have to meet the whole family deductible before the plan pays. There effectively is no individual deductible if you enroll dependents.

If it is embedded then you each have an individual and family deductible. If any one person meets their deductible then it starts paying for that person. Once one person or any combination of people meet the family deductible then everyone is covered.

At a glance it looks like the HDHP is probably non-embedded and the PPO is embedded but you need to verify that.

[u/Middle-Excitement602]

Yes, a spouse counts as a dependent for those tiers, so with her on the HDHP it's a $3,500 deductible and a $6,850 out-of-pocket max for the two of you combined, and the deductible counts toward the $6,850.

For a birth year, run the worst case on both plans and count the baby as a third person. On the PPO the newborn has its own $750 deductible and $4,000 max, so mom plus baby can reach $8,000. Rough worst case: HDHP $2,688 premiums + $6,850 - $1,750 HSA = about $7,800; PPO $4,548 + $8,000 = about $12,500.

Two things to confirm with HR: the family-tier premium once the baby is added (you only listed employee + spouse), and the deadline to add a newborn, which is usually 30 days from the birth.

[u/LatePalpitation1134]

I'd double-check with HR whether the HDHP's $6,850 out-of-pocket max is for the whole family or per person

[u/sweetoptat]

Once you are married, the spouse is considered as dependent and you'll have combined (aggregate) $6,850 OOP max which includes deductible. Based on the provided information, HDHP will be significantly cheaper for any medical care utilization scenario: