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How U.S. Health Insurance Works

Medicine in the USA is very expensive, therefore. We have prepared a small overview of health insurance. Is medical insurance mandatory in the USA? What types of insurance do exist? How much does it cost and where to get it? You will find the answers below!

Are Americans obligated to purchase insurance?

Yes, according to the Affordable Care Act, every American is required to have health insurance. In the event that a US resident does not have health insurance, he or she will have to pay his or her own medical expenses and pay a fine to the state for evading compulsory insurance.

How to get health insurance?

Health insurance is obtained in several ways:

  1. Poor people, people with disabilities and the unemployed are paid by the government (Medicaid);
  2. If there is income but it is limited and the employer does not pay you insurance, you will have to purchase it yourself, but part of the insurance premiums will be compensated by the state;
  3. If you work, the employer may pay for your insurance partially or in full. This is much more profitable than an independent purchase;
  4. Business owners and those for whom the employer does not pay insurance are required to buy insurance at their own expense;
  5. Young people under 26 years of age can take out insurance through their parents;
  6. Government-subsidized Medicare insurance – for people over 65.

Does US health insurance provide free health care?

No, US health insurance covers only part of the cost, but given the high cost of medical services, this is your safety net against excessively high costs. The Americans joke that buying insurance actually insures against ruin. For example, if you have insurance, an ambulance call will cost you $240, but if there is no insurance, you will have to pay an average of $5000.

Specialists from weavervilledrug.com remind you that no insurance plan will cover every medication available on the market. So before you choose a health plan, make sure it covers the prescriptions you need.

How does it work?

You go to the doctor and show your insurance. The registry contains all the necessary information. Then you go to the doctor. Based on the conditions of insurance, you are informed whether you need to pay extra money for a doctor’s visit. The conditions are as follows:

  • co-pay is a fixed amount that must be paid for each medical service, and the insurance company covers the rest of the cost;
  • deductible – this is the money that you spend seeking medical care before insurance coverage begins;
  • co-insurance — you pay interest agreed with the insurance, and the rest is paid by the insurance company;
  • out-of-pocket maximum is the maximum amount you spend during the year and you get 100% compensation from the insurance company.

At the end of treatment, all documentation is sent to the insurance company, which covers all the expenses, according to your policy. You will receive an Explanation of Benefits about the cost of the medical services, how much the insurance has covered and how much you still have to pay (if necessary).

Where to buy insurance?

Earlier insurance could be purchased directly from insurance companies, but now it is only sold through a special resource healthcare.gov. The site contains information about all insurance plans and you can choose the right one.

You also need to consider that you can buy insurance only during the period from November 15 to February 15.

Insurance types and plans

There are two main types of insurance policies:

  1. Health maintenance organizations (HMO) – the most budget option, which makes it possible for you to be treated only in a certain network of medical clinics (a very limited number). This insurance policy will not apply if you contact a private practitioner. There is also the Exclusive Provider Organization (EPO) — a hybrid health insurance plan in which a primary care provider is not necessary;
  2. Preferred provider organizations (PPO) – you choose which doctor to visit for treatment. But a contract with your insurance (in-network) must be concluded at the selected clinic – in this case, treatment will no be expensive. If the contract is not concluded (out-of-network), then medical services will cost more. The list of clinics is much wider than that with HMO, and even if the clinic is not on the list, it will still be cheaper than with HMOs.

You also need to choose a plan – it determines your payments and compensation from your insurer:

  • Platinum – insurance pays 90% of the costs, but the monthly premiums on this policy are the highest;
  • Gold — 80% compensation;
  • Silver — 70% compensation;
  • Bronze – 60% compensation. By the way, this is one of the most popular and affordable types of insurance plans;
  • Minimal. This plan is only suitable for people under 30 years of age and those who for any reason have lost their current insurance. The tariff plan only compensates for the most basic medical services.

How much is health insurance?

The cost is based on what type of insurance and tariff plan you have chosen. The average cost of insurance for an adult is $250-350 per month. Thus, families with children spend more than $1,000 on insurance each month.

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