Health Insurance and Healthcare in the US Explained

How Healthcare Works in the US

The healthcare system in the US is comprised of both private and public sectors. However, the coverage provided by public healthcare is very limited and mostly reserved for people that cannot afford other types of healthcare. That means that many expats that move to the US will most likely need to get private insurance.

Note that public healthcare has been a popular debate topic in the US for years and the system is in a constant state of change. Make sure to keep track of any updates regarding the matter when planning on moving to the US.

US Healthcare Glossary

These are a few concepts you have to understand before getting into how the US health system works:

• A monthly premium is a monthly fee for your insurance that you have to pay regardless whether you use medical services or not.
• A deductible is a fee you need to pay before your insurance starts covering the medical fees. Usually, that means that you have to pay full price for services until your payment covers the deductible.
• Coinsurance is a percentage you have to pay on services in addition to what insurance already covers. This comes after the deductible is covered and requires you to split your bill with the insurer (40% and 60%, 30% and 70%, etc., depending on your insurance plan).
• Health Insurance Marketplace (or simply marketplace) is a group of private insurers that provide insurance plans that meet basic standards set by the government (Affordable Care Act). Even though the rules are the same, each state has its own marketplace with different companies in it.
• Short-term insurance plan does not meet the government standards and does not belong to the marketplace. These plans are usually cheaper; however, they do not provide comprehensive coverage.

Does the US Have Free Public Healthcare?

Theoretically, yes. However, how the public healthcare works in the US is different from most other developed countries as it is not universal. Public healthcare is only available for people of a certain age and income. Most working expats will not be eligible to receive free public healthcare in the US.

Who and What Does the Public Healthcare in the US Cover?

The US runs a few publicly funded programs that help over 50% of the population. Those are Medicare, Medicaid, and Children’s Health Insurance Program (CHIP).

Medicare

Medicare is a program run by the US government that is split into four parts:

• Part A – covers hospital inpatient care;
• Part B – helps pay for services from doctors and outpatient care;
• Part C – combines both parts A and B into one package, with a possibility of some additional benefits;
• Part D – helps to cover the costs of prescription drugs.

Most citizens and permanent residents over the age of 65 are covered by Medicare Part A. You are also eligible for this part of Medicare if

• you have been entitled to receive disability benefits for 24 months;
• you have permanent kidney failure;
• you have Lou Gehrig’s disease (ALS).

Medicare Part B usually comes at additional costs no matter whether you are eligible for Part A or not. Part B can be purchased separately (or added to your Part A plan) if you are 65 years old or older and

• a lawfully admitted noncitizen that has lived in the US for at least five years;
• a US citizen.

Part A and B of Medicare together constitute the original Medicare. You can buy additional supplements for the plan (Medigap) from private insurance companies.

Medicare Part C is the Medicare Advantage Plan that in addition to Part A and B coverage, also includes extra benefits (more days at the hospital, vision and dental coverage, etc.). This plan is usually provided by a private company or Medicare Advantage Organization.

If you wish to receive coverage for prescription drugs, you will have to pay a monthly premium for the addition of Medicare Part D.

Once you become eligible for any part of Medicare, you will be automatically enrolled in Parts A and B; however, as part B requires additional payments, you can always opt out of it. Note that the states provide financial support for people who cannot afford the additional parts of Medicare.

Medicaid and Children’s Health Insurance Program (CHIP)

Medicaid is a state-run program that

• helps with medicals costs for people with low income;
• offers additional benefits that are not covered by Medicare.

Each state has its own set of eligibility rules that might include your:

• age;
• income;
• disability or state of health;
• immigration status.

Keep in mind that in most cases you are eligible to receive Medicaid after holding residency in the US for five years.

Children’s Health Insurance Program has similar rules regarding eligibility. It covers healthcare (both medical and dental care) costs for children under 19 years of age.

About half of the states in the US can provide Medicaid and CHIP for immigrant children and pregnant women.

Public Healthcare Costs in the US

The following table notes the average prices of public healthcare plans if you are not eligible for a free program. The fees depend on many factors, so make sure to check the exact sums you need to pay before choosing your healthcare plan.

Deductible is the fee you need to pay before you receive certain services. Usually, that means that you have to pay full price for the services until the sum covers the deductible. With Part A you will need to pay a deductible for being submitted to the hospital (around 1,400 USD).

Coinsurance is a percentage you have to pay in addition to what insurance already covers. This comes after the deductible is covered and requires you to split your bill with the insurer (40% and 60%, 30% and 70%, etc. depending on your insurance plan). In the case of Part A, you will need to pay coinsurance for days spent in the healthcare facility after a certain period of time (350-700 USD).

Why is US Healthcare so Expensive?

Because there are no government regulations on the prices for healthcare procedures, private insurance companies, various medical institutions, and pharmaceutical companies can allow themselves to drive up the prices for their services to what they deem appropriate. People also tend to do more tests and choose more costly procedures, while the medical staff in the US tends to get higher wages.

The Pros and Cons of the US Healthcare System and Other Healthcare Facts

Pros Cons High-quality services You have to pay for most procedures A wide range of options Healthcare services are expensive thus not accessible to all Short waiting times Medication is expensive

US Healthcare Facts

• While the public coverage is not universal, most employers will provide you and your family with an appropriate health insurance.
• Ambulance rides might get very expensive if you are not insured (cost vary depending on the location but can go from 400 to 1,200 USD).
• The most common causes of death in the US are cardiovascular diseases and cancer.

An Overview of Private Health Insurance

The US healthcare market offers plenty of private health insurance options for people living in the country. The health insurance plans differ in coverage and pricing which means that everyone can find a plan that suits their needs. That being said, most plans that provide full-coverage are expensive and the majority of people cannot afford it.

How does Private Health Insurance Work in the US?

Without public health insurance, there are a few ways of how you can get health insurance in the US. These are:

• Getting employment-based coverage (yours, your spouse’s, or your parent’s).
• Purchasing health insurance through the Health Insurance Marketplace.
• Purchasing health insurance directly through a health insurance company.

Many workers are usually covered by some kind of employment-based health insurance. However, the plans are not always sufficient, and some people choose to pay for the premiums in order to get better coverage.

If you are self-employed, you are free to purchase your medical insurance from the marketplace or directly through an insurance company.

Types of Health Insurance Plans in the US

As mentioned before, when choosing your plan, you can

• opt for insurance plans that comply with government standards (sometimes referred to as Obamacare or Affordable Care Act plans);
• choose short-term plans offered by insurers.

If opting from the government-regulated plan, you will be able to choose between the following networks of the marketplace:

• Preferred Provider Organizations (PPO): allows the members to visit doctors inside and outside of the network. The costs for specialists outside of the network might be higher. Allows members to visit any doctor without a referral.
• Point of Service Plan (POS): allows the members to visit doctors inside and outside of the network, with higher costs for out-of-network specialists. Members need a referral to visit providers that are outside of their network.
• Health Maintenance Organizations (HMO): covers healthcare services provided by specialists and hospitals in the network and out-of-network emergency services. The members usually have their primary doctors who refer them to specialists.
• Exclusive Provider Organizations (EPO): covers healthcare services provided by specific specialists and hospitals that are a part of the network.

As a lot of insurers are in the marketplace, you will see the appropriate acronym of each network indicated in the description of the plans they are offering.

Most insurers in the marketplace also allow you to choose between plans categorized into metal types:

Typically, people who do not need constant care or prescription drugs are recommended to choose the Bronze plan. The monthly payments (called monthly premiums) for a plan like that are low, and the plan protects you in case of a serious illness; however, most routine checkups will have to be paid out of pocket as deductibles are pretty high.

The silver plan is only recommended for people that qualify for extra savings as without them it provides the same kind of coverage as the Bronze plan, just at a higher price.

Gold and platinum plans are the best for people that need a lot of medical care. Monthly premiums with these plans are higher, but the coverage is more comprehensive.

Most basic plans financially contribute to cover your hospital stays, outpatient and emergency care, as well as specialist appointments, and prescription drug fees.

Average Costs for the US Health Insurance

The following table shows the monthly average of how much you might pay for health insurance in the US. Note that the price usually depends on your age, how healthy you are, what is included in your plan, and which state you live in.

Most insurance plans can have added bonuses to them. The most common of those are dental and vision care and can cost you an additional 50 USD per person each month. You can also take out additional bonuses from insurers if your employer does not cover you and your family adequately enough.

The Affordable Care Act (Obamacare)

The Affordable Care Act was started in order to make healthcare more accessible to the public. The main changes made by the Affordable Care Act are:

• Eliminated lifetime and yearly coverage limits.
• Ability to purchase health insurance through government-regulated Health Insurance Marketplace.
• Permission for adults under 26 years old to stay under their family’s insurance plan.
• Refusal of coverage based on gender or pre-existing conditions.

The act also introduced a yearly fine for people that do not purchase any insurance as well as the concept of ten essential healthcare benefits that must be covered by the qualifying health plans. However, the recent policy changes aim to eliminate those clauses and make other alterations in the act.

Do You Need Private Health Insurance in the US?

All in all, yes, you do need private health insurance in the US. And that is not only because according to the current laws you can still be fined for not being insured. Getting insured is in your best interest because healthcare in the US is expensive and any unexpected bills can cost a fortune for you and your family.

How to Find a Doctor or Dentist

Finding a doctor or a dentist in the US should not be too complicated. The country offers plenty of medical field professionals that can help you and your family.

How to Find a Family Doctor in the US

When looking for a suitable medical practitioner, start by contacting your insurance company. They should provide you with a list of local doctors that are available under your plan. Then, browse online databases for more information on practitioners that you prefer. Do consider recommendations from friends and colleagues – their first-hand experience can assure you about whether or not you are making the right choice regarding a physician. The next step is contacting the doctor of your preference and arranging your first appointment.

What to Pay Attention to when Choosing a Doctor

• How close to your home are the hospitals/clinics the doctor is working at?
• What are the doctors’ usual working hours?
• How accessible is the doctor? What is the average waiting time for an appointment?
• What is the doctor’s experience in the field?
• What is the doctor’s approach to treating their patients?
• What is the doctor’s approach to communicating with their patients?

Family doctors (also known as general practitioners (GP) or primary care specialists) are the medical professionals that are in charge of your health. In some cases, they are also the ones that will refer you to other medical specialists, so choosing a doctor that suits all your needs is crucial. That is why, once you settle or one or a few doctors whose profiles you like, arrange an appointment to see if they meet your expectations.

During the first meeting with a family doctor, you will be asked about your medical history, your health condition, and other personal details so, be prepared to provide appropriate information. Bring your ID and the medical records from your previous doctor in order for the first appointment to go smoothly. Do not be afraid to ask questions yourself.

If after the first appointment you feel that the doctor is not the right fit, continue looking. You will need to discuss very personal matters with your doctor, so feeling comfortable with them is important.

How to Find a Specialist Doctor in the US

According to your insurance plan, you might need your family doctor’s referral in order to book an appointment with a specialist doctor; however, that does not mean that you cannot look into options available to you yourself.

Online databases that allow you to find medical professionals in your area include the following:

• Medicare.gov allows you to compare physicians whose services are covered by Medicare. The database indicates each doctor’s field and education as well as the location of their practice.
• American Medical Association lets you browse through their list of certified doctors. You can look for them according to specialty and location. The search indicates each doctor’s education and the location of their practice.
• US News lists all the available doctors according to their field and location. The database includes information about each doctor’s experience, expertise, spoken languages, patient rating, and contact information.
• Medicineplus.gov and healthfinder.gov provided directories for specialty doctor organizations.

There are also apps like ZocDoc that allows you to look for a doctor in your area and book an appointment with them. The search filters include specialty, gender, availability, hospital affiliations, and languages spoken. Apps like Practo also lets you chat with your doctor online.

How to Find a Dentist in the US

American Association of Endodontists and Academy of General Dentistry both have their own databases in which you can look up dentists located in your area. There you can find information on each doctor’s education as well as their contact information.

Most basic insurance plans do not cover dental care so, you will be able to choose whichever dentist you like, in most cases; however, as the costs will not be covered by the insurance, make sure you know the costs of any procedures you need.

If your insurance includes a dental plan, you will be able to choose a dentist from a list of practitioners suggested by your insurance company.

Average Wait Time for a Doctor’s Appointment*

Waiting for an appointment in a US hospital or clinic should not take you too long. While highly-populated areas and well-known specialists might be an exception to this, usually you do not need to wait much longer than a few weeks for your doctor’s visit.

The following table indicates waiting times in major cities of the US. Keep in mind that the wait times for doctor appointments vary depending on the hospital and the area where it is located.

*According to a survey conducted by Merritt Hawkins Healthcare Company

Giving Birth in the US

When giving birth in the US, being a citizen, non-resident, or a green card holder does not make a big difference, legally. If you deliver your baby in the US, your child has the right to US citizenship.

However, the main challenge of having a baby in the US, whether you are a foreigner or not, is usually paying the hospital bills. That is why it is important for all partners that are planning on having children while in the US to inform their insurance company about their intentions. That way their insurance plans can be adjusted to cover maternity care.

It is also important to consider maternity and paternity leave options when planning your budget.

Cost of Having a Baby in the US

The costs of delivering a baby vary from hospital to hospital and from one state to another. The following table indicated the average costs of childbirth, maternity, and newborn care, according to Truven Health Analytics study. It does not include the costs of prenatal care, which usually adds another 3,000-4,000 USD to the total bill.

Keep in mind that if you are giving birth in the US without health insurance, you will need to pay full price for all maternity care; however, if you are a pregnant, uninsured citizen, in some states you might qualify for Medicaid which can help you with the hefty hospital bills.

Benefits of Giving Birth in the US

As mentioned above, you do not need to be a permanent, or even a temporary resident in the US in order to give birth to a US citizen. The US is one of the few countries that allows for birthright citizenship. That means any child born in the US will automatically qualify as a US citizen.

Another benefit of giving birth in the country is the possibility to obtain a green card through your child. Once the child turns 21 years old, their immediate relatives become eligible for permanent residence. US citizens can sponsor several immediate relatives, so it is not uncommon for citizens to bring their whole family to the US. Because of that, birth tourism (traveling to the US and giving birth there to get citizenship) has been very popular in the country.

However, being the parent of a US citizen does not grant you the right to live in the country. Until the child turns 21, their parents or other family members currently on the US soil are expected to live in the country lawfully under their own visa. Keep in mind that if your motives are considered unlawful (for example, you entered on a tourist visa with the intention of giving birth), you could be considered inadmissible to the US.

If your situation is lawful and your child is able to sponsor you, you can apply for a green card by adjustment of status if you are legally in the US or otherwise apply through consular processing.

How to Get Your Child’s Birth Certificate

When you arrive at a hospital to deliver your baby, you will be asked to fill in documents that will be sent to the state to issue your child’s birth certificate. In some hospitals, you might be asked to do so yourself.