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A simple explanation of the complex medical insurance system in the USA: the immigrant’s personal experience

Health insurance in the United States is a very sensitive topic. Especially for those who have recently moved and are in the country without a green card. Author blog "Here you are not there - about life in the USA" on "Yandex.Zen" put on the shelves all the most important information about health insurance in the United States.

Photo: Shutterstock

Next - from the first person.

State health insurance exists, but it is only for the elderly, either for the military or for low-income families. But the choice of clinics for the poor is not particularly rich, as are the areas in which they are located.

Ordinary people have to buy medical insurance themselves and their families.

Your employer can also provide insurance, but then the monthly cost of insurance will be deducted from your salary.

There are three types of health insurance in the USA:

  1. Dental (dental insurance).
  2. Ophthalmic (vision insurance).
  3. General medical (health insurance).

The employer usually draws up all three of these types at once. Insurance is issued at several large companies represented in the American market: Aetna, UnitedHealth, MetLife. It is not necessary that all insurance be in the same company.

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For example, we have health insurance from Aetna, dental insurance from MetLife, and eye insurance from VSP.

Medical services in the US are insanely expensive, so without insurance you can easily drown in medical debt. Looking at statistics on the causes of bankruptcy of Americans, you can easily understand that it is not worth it to be sick in the USA.

A simple example: a physical therapist’s visit without insurance can cost up to $ 400. If you are with something serious and urgent, for example, with a fracture, you are in emergency room and spent a couple of hours there with several procedures, you can bill up to $ 10.

For each employer, insurance companies develop individual plans. So the conditions can vary greatly depending on the insurance and the employer.

If described in general terms, then the monthly amount for insurance from the employee is deducted from the salary. Moreover, this amount depends on how many family members are included in the insurance.

It is possible not to pay anything for insurance, but then this plan will involve a large deductible. That is, for example, I will pay the first $ 10 a year for medical expenses from my pocket, insurance will cover the rest. Such a plan is good because every month nothing is deducted from the salary, and if no one is sick, then no spending happens.

If something big happened, the insurance will cover everything except the first $ 10.

Each insurance company has a list of collaborating doctors and hospitals (network). The doctor’s contacts are usually searched through the insurance website, after which you call him, make an appointment and specify the cost of the appointment. Even if you have a large insurance deductible, the cost of seeing a doctor on a network will be cheaper than on a doctor out of network.

Each doctor has his own rules, but in general, most doctors will not pay anything on site for an appointment. Then the insurance will invoice you, and then you will deal with it.

Most drugs in the United States are sold by prescription only and can only be given by a doctor. All prescriptions are made on the doctor’s nameplate, where his name, position, license number, address of the clinic where he receives, and your insurance information are indicated.

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You give this prescription to the pharmacy, after which the pharmacist contacts your insurance provider to determine who will pay for the medicine and what is the final cost. You can get the prescription in your hands at the clinic or ask to be sent immediately to a pharmacy convenient to you. Sometimes the insurance company may express disagreement with the prescription and then the pharmacist will contact the insurance and the doctor himself, and they will jointly decide how to replace the prescribed drug. Everything is very individual and depends on your plan, and sometimes on the human factor.

The pharmacist will give you exactly as much medicine as the doctor prescribed, no more and no less. In addition, if the prescription allows, then you can do the Refill of the prescription and get the same amount of medicine again without visiting a doctor. This type of prescription depends on the doctor.

So one doctor wrote us a prescription with medicines for only a month, without the possibility of extending without a visit, and another doctor for two months. Which at least saved us $ 250.

In some states, even home medical equipment can be sold strictly by prescription. In New Jersey, for example, you cannot buy an over-the-counter nebulizer.

About the teeth. Most dental plans cover most of the costs (ours covers 80%), and at the same time we pay nothing for it per month.

Eye insurance also covers up to 80% of the costs, plus it usually has a free eye test once a year + free eyeglass frames (lens manufacturing usually covers up to 70%).

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