What's Your Experience with a High Deductible HMO?

Updated on November 03, 2013
T.D. asks from Roseville, CA
12 answers

Hi everyone,

I'm thinking about switching my family to HD HMO instead of a regular HMO. My research sounds great and seems this is the way to go however I'm not sure if there are any hidden charges/catch. To switch over to this plan we are saving $1000.00/month. My understanding regarding HD HMO is once we spend $3000 for the family, everything is free for the year, minus the chiroprator and acupuncture service. We can also roll over what we don't use. (I know this is true because I called the insurance company. What's your experience with this? Thanks.

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answers from Chicago on

Usually it isn't free, it hits 90% payment.

We've been doing a high deductible for years. We love it. Hubby's company pays us to be on the plan, so we don't have any premiums. It's great. However, we do have to spend 5k before they pay anything...

And yes, the money does roll over. Actually, it doesn't roll over. It's a savings account, like any other, than you use for medical expenses. I love this plan because if you have a no medical year, you end up saving money for higher cost years.

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answers from New York on

Be very careful. What about co pays, co insurance and maximum out of pocket. Would this begin Jan. 2014 or were you quoted this for Nov. and Dec. Be careful. Obamacare has really screwed over everyone. As of Jan
Every policy must include the "10 Essentials." I have been searching for insurance for my daughter since Oct. 1. I am very well versed in this. So look at everything. Any questions PM me. Good luck.

2 moms found this helpful


answers from Milwaukee on

Oh my goodness-just reading these responses terrifies me. People do not even understand their own plan and yet want to jump in and offer you their two cents.

I assume you are talking about switching to a HDHP plan away from an HMO plan that has co-pays etc...Is that correct?

Jill is wrong (sorry) when she says that your deductible isn't eligible. The deductible can be as low as $1250 for single coverage (2500 for family) so yours is more than eligible. The amounts she is stating is how much you can put into a qualified HSA account.

ACA did have the preventative health in it and a lot of plans are changing but some employers/plans saw this coming or saw the benefit of people getting regular maintenance to prevent the big blow ups and did it earlier. Some did not and those will have to change.

And yes-the prescriptions would be one of the biggest concerns. Is anyone on any brand name or designer drugs because if they are-you pay the negotiated discounted price-which can be a lot. It does go towards your deductible but it is a lot out of pocket up front.

And I had to chuckle at Maria's complaint that $1000 was too high of a deductible-ours at work has been 2500 pp for years now. It is just the trend. And it will get worse.

Knock on wood that we are very healthy :)

Oh and one other thing-just a warning about that thought that everything is covered once you meet the deductible-it's not ever true. There are always things that have limits or just aren't covered per the plans summary plan description.

What you need to do is be realistic about your health expenses as a family, look at the cost between the two plans and decide if it pays to switch.

The HDHP is a tool to get you more informed as a consumer. People with super low deductibles tend to go to the doctor for the sniffles and the emergency room for the flu-just an exaggeration but you get the idea.

Good luck in your decision making processes :)

Oh-one more thing you should ask is if it has an embedded deductible? This would mean that if you are in a car accident by yourself-you would pay your part (1500 pp) and then the insurance would kick in. Then say the rest of your family is perfectly fine-you are only out the 1500. Or if one of you is very sickly-it would matter.

1 mom found this helpful


answers from Dallas on

Either you don't understand or you aren't explaining it well. You can fund your deductible though an HSA account and what you don't use will roll over to the next year. Without the HSA nothing rolls over.

So what you really need to look at as the costs are 250 a month to fund the HSA plus what ever the charge is for the actual insurance. If it is saving you 1,000 a month it will still save you 750 a month and you will end up with a fully funded HSA.

For all our routine visits we use about 1,200 of our HSA balance. The rest rolls over. We always fully fund every year. The money in your HSA can be used for any health expenses so like this year when my husband had dental work we paid that balance with money that was rolled over in our HSA that way regardless of what ever happens we have that deductible covered.



answers from Detroit on

read carefully.. make suer you understand exactly what is covered and when.. I was paying crazy high prices for prescriptions.. I was wondering what kind of percentage I was supposed to pay... so I called and prescription drugs are part of the deductible. so they were not covered until I payed $3000.

we have had plans like you are alooking at several times.. it can be great. for some reason.. folks don't mind paying high prices for insurance.. but they hate to write a check for a dr visit. our insurance is cheap.. but has a high deductible.. but my MIL thinks it is a horrible plan.. cause her deductible is so low.. but hse has to pay $5000 a year in premiums..



answers from Houston on

We have a $3, 000 deductible. Pay for everything until we meet it. We use the money we put into an hsa. We don't even get close to 3k each year.

FWIW, our insurance was phenomenal (and affordable!!) until about 3 years ago.



answers from Wausau on

We've had a HD plan for awhile now but ours is PPO. It means we don't have to select a primary care doctor and we don't need to get referred to see other doctors and specialists.

Our preventive care is covered 100% and we pay nothing out of pocket.
(It has always been this way, and not a new thing due to the ACA.)

For other care, including prescriptions, we're billed the amount contracted with insurance. Insurance pays nothing until the deductible is met.

After we pay out-of-pocket to the amount of our deductible, then insurance will pay 80% in-network and we'll have a 20% copay, until the point we reach the Maximum OOP amount. Then insurance would pay 100%

We never reach our deductible, so something huge would have to go down before we'd reach the 100% coverage mark.

We pay less than $100/mo in premiums for family coverage but our deductible is $6400. Our HDHP qualifies for an HSA, which we use to save money tax-free each payday. The money and the account belongs to us, even if the insurance or job is lost. (HSA money can also be used to pay chiropractors, acupuncture, vision, dental, etc.)

Previously, we had an FSA. An FSA is an option that an employer can choose to offer, but it is your money that funds it. Tax free money, but lost if you don't use it up each year.

The HSA money is the thing that 'rolls over'. Actually, it doesn't roll at all, it just continues to build up as you save into it. It's yours to keep for always, but using it for non-qualified stuff will have a penalty.

(There are also HRA plans, where the HRA money does roll over. You lose it when you lose the job or insurance though. The money belongs to the employer.)

Edited: I had mistakenly quotes HSA contribution limits as HSA-qualified deductible amounts. Kristine was right, your plan does have a high enough deductible.



answers from Washington DC on

We just switched to a deductible plan and I was shocked when I went in for my annual well-woman exam and thought everything was covered since you get one exam per year without a charge. Well, it turns out, one lab procedure wasn't included and I got a $400 bill. OMG, nobody warned me that it wasn't part of the annual exam. Question everything before you actually have any lab, radiology, etc. Call the business office and get a quote.



answers from New York on

We opted for a high deductible this year, mainly because I figured out the difference in premiums and even if we paid the entire deductible we STILL came out cheaper than the higher monthly premium costs. I'm not sure with that what any "catch" would be - I still get the insurance discounted rates. I just have some sticker shock when I get a bill I have to pay.

My only dilemma I have faced was when I needed to go to urgent care. The one my insurance pays for is REALLY expensive - it's like a mini hospital. I'd been used to going to the cheap one down the street that cost me around $100 for a visit for my bronchitis. Of course I reminded myself it was going toward my deductible, but if I get sick on a weekend this winter I'm not sure what I'm going to do.



answers from San Antonio on

I don't like HMOs...I was in one and ran into issues about which doctors I could and couldn't see. In Texas if you are in an HMO, you can't even see a non-HMO doctor and pay out of pocket (it is against the law...that is a long story and was played out with my two day old infant).

Anyways...the savings sound great...but make sure that once the deductible is met it really is 100% covered.

Our expensive PPO...is only 80% covered after the $5000 deductible has been met. We have never met the deductible even with a hospital stay and a broken leg in the same year.

I know PPOs and HMOs are apples to oranges comparison...but get all the details in writing and read all the fine print...then re-read it again...

If you do change put at least half the savings from the difference in price in an HSA...and look for states that let you roll your health savings over..in Texas if you don't use the money in your health savings account in the calendar year you lose it...we have a HSA set up online in another state...

Good luck!! heath insurance is tricky business and getting trickier...



answers from San Francisco on

I had a high deductible plan with Kaiser for a couple of years and I basically stopped going to the doctor, even for check-ups. Yes, preventive care was "free", but it seemed like a lot of people from my company were going in for "free" check-ups and coming home with big, unexpected bills for extra tests, etc. What was worse was that, even if you asked how much the extra tests were going to cost, it was 100% impossible to get a reliable answer. Many quotes were given that were wayyyyy off from the final bill received.

That said, $1,000/month is huge savings, and if you were to put aside even half that for medical expenses you'd have a $6,000 cushion you could put toward medical expenses. I just found it a lot harder to pay out of pocket for my office visits, etc. I started going to Google for almost all of my medical information. Thankfully, I never got really sick, but if I had, I guess my insurance would have kicked in anyway.

Good luck!



answers from Boston on

Be very careful....my hubby and I both work for HMO's ....2 different and competing ones....we're in the process of switching coverage over to mine, no deductible (yes, I just returned to work at the hmo after a long hiatus)...Hubby's has a $1000 annual per member deductible....which has nothing to do w/ Obamacare....these high deductible hmo's started, at least in Mass. under the Bush administration.....And even with high deductibles, nothing is ever truly free.....

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