The HMO deductible is the amount you have to pay toward your actual medical
bills before your insurance policy starts paying out. For example, an HMO policy with a
$1,000 deductible requires you to pay the first $1,000 of your medical bills; then your
coverage will start ( Premiums and Deductibles, 2007). When you have a higher
deductible, you typically get a lower premium. The co-payment or "copay," is a
fixed-dollar amount that you have to pay each time you get healthcare services. In HMO
plans, the copay for a doctor visit is often as low as $10. Most HMOs reimburse 80
percent of covered allowable expenses after the annual deductible of $250 to $500 per
person or $750 per family has been met (Medical and Dental Plans, 2007). The maximum
out-of-pocket expenses per calendar year for most HMO plans are $1,000 per participant
and $2,000 per family (Premiums and Deductibles, 2007).
HMO Prescription Drug Plans normally includes a $5 co-pay for generic
prescriptions and a $13 co-pay for name brand medications. HMO Dental pays preventive
care at 100 percent of usual and customary charges with no deductible. Preventive care
covers two cleanings per year, bitewing x-rays once a year, and full-mouth x-rays every 3
years. Restorative services, such as fillings, are reimbursed at 80 percent, and major
services such as crowns and dentures, are covered at 50 percent. Both restorative and
major services have a deductible ($50 per person or $150 per family) that is separate from
the medical deductible. The plan requires pre-certification for services over $200 and has
a maximum annual benefit of $1,000 per per ...