Usually I see HSA’s combined with a high deductible plan so that the six figure medical bill is protected. We were on one when my daughter needed surgery (~$50k). We also had another child the same year ($20k), and all we paid was the $6k deductible which also came out of pre-tax money AND my employer contributed $3k to cover the premium. There were no bank fees involved. i am now self employed. Unfortunately I can not buy a high deductible or a HSA plan in my state post Obama care and my premiums in 2018 where $38k and this year have dropped to $32k. To be honest I kind of miss that $6k deductible.