An HDHP Year With an Out-of-Network Anesthesiologist and an HSA Overfund
The Okonkwo family is covered by the employer's HDHP: a $3,500 aggregate family deductible, 20% coinsurance after the deductible, an $8,000 in-network family out-of-pocket maximum, and no out-of-network coverage except emergencies. The employer deposits $1,200 into the family HSA each January; payroll deducts the rest. In March, Ada has an in-network appendectomy with allowed charges of $42,000. In April her husband Chidi has an in-network MRI billed at $2,600. In May their son has a preventive well-child visit and a separate sick visit billed at $180. In June an anesthesiologist from the surgical group-out of network, although the hospital and surgeon were in network-sends Ada a $3,200 bill that the plan paid nothing toward. Total family HSA contributions for the year are $9,600 including the employer's $1,200; Chidi is 57.
1. Walk through the family's cost sharing for the year and state the total they owe for the surgical, MRI, and office claims.
Read the worked answer
March - appendectomy ($42,000 allowed, in network).
- The full $3,500 family deductible is satisfied because the plan uses an aggregate (non-embedded) family deductible - one member's expenses can meet the whole family deductible.
- Remaining $38,500 × 20% coinsurance = $7,700.
- $3,500 + $7,700 = $11,200, which exceeds the $8,000 out-of-pocket maximum, so cost sharing is capped: the family pays $8,000 and the plan pays the remaining $34,000.
April - MRI ($2,600, in network). The out-of-pocket maximum is already met, so the plan pays 100% and the family pays $0.
May - preventive well-child visit. Required to be covered with no cost sharing, so $0. The separate problem-focused sick visit is also $0 because the maximum is met.
Year total for these claims: $8,000, all of it in March.
The reasoning hinges on two structural facts: an aggregate deductible lets one member's claim satisfy the family deductible, and once the out-of-pocket maximum is reached the plan pays 100% of covered in-network benefits for the rest of the year. The maximum counts in-network cost sharing for essential benefits only - not the anesthesiologist's bill discussed separately.
2. Does the family have to pay the $3,200 anesthesiologist bill? What should they do?
Read the worked answer
They should not pay it. This is a classic surprise-billing fact pattern: a non-emergency procedure at an in-network facility, performed by an in-network surgeon, with an out-of-network ancillary provider (anesthesiologist) the patient did not choose.
The protection: federal balance-billing rules bar out-of-network providers in this situation - and in emergencies - from billing the patient beyond in-network cost sharing. The patient's responsibility is limited to what an in-network provider would have cost. Here that amount is $0, because the family met its out-of-pocket maximum in March. The insurer and the provider are left to settle through the required payment process, including arbitration if they cannot agree.
Practical steps:
- Do not pay the $3,200; paying it voluntarily can be treated as accepting the balance.
- Send the bill to the insurer and ask that the claim be reprocessed as in network under surprise-billing rules.
- Get written confirmation that the claim was adjusted and that the family owes nothing.
- If the provider keeps billing or reports to collections, file a complaint with the federal agency that enforces the rules and with the state insurance department.
- Keep the documentation - the dispute is a paperwork problem, not a coverage problem.
The family should also confirm the plan has no out-of-network deductible they were wrongly charged against; the maximum applies to in-network cost sharing.
3. The family contributed $9,600 to the HSA for the year. Compute the allowable amount and explain the correction.
Read the worked answer
The allowable contribution is $9,550.
- Family-coverage HSA limit for the year: $8,550.
- Chidi is 57, so he is eligible for the $1,000 catch-up contribution.
- $8,550 + $1,000 = $9,550 maximum.
Excess: $9,600 − $9,550 = $50.
Three things the family needs to understand:
- The employer's $1,200 counts toward the same annual limit as the payroll contributions. Employees routinely forget this and overfund.
- The catch-up belongs to Chidi individually; it is available because he, not just the account, is 55 or older. If both spouses were 55+, each would need to use their own catch-up in their own HSA - a single family account cannot absorb two catch-ups.
- HSA eligibility requires HDHP coverage with no disqualifying other coverage; nothing in the facts breaks eligibility.
Correction: withdraw the $50 plus attributable earnings before the tax filing deadline (including extensions). If it is withdrawn timely, it is not taxed and no excise tax applies. If it is left in, a 6% excise tax applies to the excess and repeats every year the excess stays in the account; it can also be absorbed by contributing less in a later year while remaining an eligible individual.
The judgment point is that the employer contribution and the payroll contribution are one bucket against one statutory limit - not two separate allowances.