Most consumers understand that saving for a new car, retirement or child’s college education requires putting away money on a regular basis. But few seem to think about setting aside funds for their health care expenses in the same way.

That creates a quandary for employers offering consumer-directed health plans. With these plans, employees must be comfortable paying their deductible, and health savings accounts offer a vehicle to make their dollars go further with tax-advantaged contributions. As CDHPs proliferate in response to market forces, their success will be contingent upon a workforce that is comfortable with using HSAs to pay and save for qualified medical expenses.

For employers, the challenge is to help employees adjust their mindset so that they think ahead about planning for health care expenses, similar to the way they save for a vacation or kitchen remodel. Although health care is not always a planned event, having funds set aside can ease the burden of both anticipated and unplanned medical care.  

Employers have their work cut out for them. While 22% of employers offer account-based CDHPs – up from 17% two years ago, according to Mercer – there is still lots of room for improvement. For example, the average HSA account balance was only about $2,350 at the end of 2013, according to Devenir Group.

What this shows is that there is great opportunity for employers to help educate their employees about using HSAs more effectively, not just to pay for immediate health care costs but also to save long-term for future health expenses – and even into retirement.

Optum recently conducted extensive research to better understand consumers who have HSAs and the reasons behind their financial habits and decisions. We found four distinct types of people who own HSAs:

1. Traditionalists have relatively high HSA balances and view their accounts as a financial planning tool to save for health care expenses in retirement.

2. Active Families need help preparing for unexpected medical expenses and ensuring their HSAs can cover deductibles and out-of-pocket maximums.

3. Stretched Singles contribute the least to their accounts and would benefit from long-term savings planning.

4. Achievers have the highest net worth and HSA balances but need help understanding how to use HSAs to plan for retirement.   

For each of these groups, we identified five distinct stages consumers take as they proceed from initially opening their HSAs to managing them. Understanding how employees’ concerns differ throughout that journey can help employers tailor education accordingly.  

The HSA journey map stages are: decide, open, use, manage and optimize.


As potential enrollees, employees at this stage explore the threshold question of whether or not to open an HSA. Some may be enthusiastic, others confused or skeptical. At this stage, employees are interested in the following:

  • What are the benefits and risks of an HSA?
  • How does an HSA work, and will it help with my health care needs?
  • How does it differ from my current plan, and will I pay more?


Employees at this stage want to open their accounts with minimal effort. Employers should provide tools to help workers forecast their health care spending for the year and calculate their contributions. They want to know:

  • How do I activate and use my debit card?
  • What should I do the first time I visit the doctor?
  • Who should I contact with questions?  


Users want to ensure that their accounts have sufficient funds for upcoming expenses and payments are properly made. Some users may feel overwhelmed and worried that the HSA won’t provide the intended benefits. At this stage, employees typically ask:

  • What happens if I pay for a medical service out-of-pocket?
  • Is the medical expense a “qualified cost” under my HSA?
  • What if my expenses are higher than I forecast?


In this stage, account holders want to stay up-to-date with account responsibilities. Some may feel empowered to take full advantage of their HSAs, while others worry they have overlooked key features. Employers should offer guidance on reimbursement rules, reconciling accounts and making changes to account settings such as payroll deduction amounts. Potential employee questions at this stage include:

  • How much – and as of what date – can I reimburse myself?
  • How do I report my account activity to the IRS?


Optimizers want to maximize the value of their accounts by investing wisely. While some will confidently choose mutual funds and rebalance their portfolio as needed, others will be apprehensive about making investment mistakes. Employees at this stage may ask questions such as:

  • How can I use my HSA to improve my long-term financial health?
  • How much money will I need in retirement to pay for my health care?

As employers increasingly embrace high-deductible health plans with HSAs, they need to ensure that their employees can effectively use their accounts. Benefit managers can leverage these consumer categories and the journey map to gain deeper insights into employees’ concerns and motivations.
These insights will help employers better understand their population so that they can better support employees on their path to taking greater ownership of their health. Ultimately, the goal is for the HSA decision-making process to become second nature to employees – just like saving for that home renovation project.

Zahoor Elahi is senior vice president, financial services with Optum.

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