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Medical insurance in the USA: how to start a choice photo

The choice of insurance is a complex and not always clear process. Photo:

Medicine in the US is private and prohibitively expensive. The state takes care only of the most vulnerable groups of the population, and, as a rule, not completely. Therefore, the availability of health insurance is a vital issue. Only children can not think about it: until 19, everyone legally residing in the USA has state insurance and can receive free medical care. The “Forum” tells you where to start choosing insurance, who can count on state help and what to do if there is no insurance.

At one's own risk

Alexey Metlitsky arrived in America from Rostov almost a year ago. He went to visit, and so he stayed: he met a girl here, fell in love. Already the wedding is over, and the room in San Francisco was removed, and the new green card arrived in the mail. The young ones had big plans - a trip to the honeymoon, for which you only had to save a little. But the trouble is: he fell, he woke up - then it’s necessary, as in “The Diamond Arm”, to write the word “gypsum”, but only there is no insurance, which means there is no gypsum either.

Alexei had to go to one of the so-called walk-in-clinics. These are medical institutions that accept patients with and without insurance. The cost of their services is relatively affordable. However, they work only with simple diseases and injuries.

“Fortunately, it turned out that the hand was simply badly hurt, there is no fracture, but I seriously thought about the issue of insurance. Now I am choosing an insurance plan, ”admits Alexey.


Alex seriously pondered the issue of buying insurance. Photo: from the personal archive

Who pays for insurance

Insurance in America is based on the principle: while you are healthy, you pay insurance, when you fall ill - the insurance company with which the contract is made, pays for you.

One of the chapters of the Affordable Care Act (or “Obamaker,” as it is called by the people) says that every legal US resident is obliged to have medical insurance. Legal residents are US citizens, green card holders, refugees, people who have been granted asylum, as well as those who are in the US on a work or student visa.

There are several ways to get insurance:

  1. Get insurance at state expense. Program Medicaid accessible for people with disabilities and low-income people, as well as for people older than 65 years (after 65 years, government-subsidized insurance Medicate).
  2. Get insurance with partial help from the state. This opportunity is available to low-income residents who are not covered by the employer.
  3. Get insurance with full or partial support of the employer.
  4. If you work, but the employer does not pay your insurance, either partially or fully, you must purchase it. independentlyby choosing the best plan.

Tatyana Sokol, who has been working for one of the insurance companies in California for 12 for years, is categorical: Every person legally residing in the USA must have insurance. Another question - what. “What insurance plan suits you personally, you can find out either by yourself, using Internet billing systemor by contacting a company that specializes in insurance, ”explains Sokol. In this case, the specialist emphasizes that usually the best insurance is selected for free. “If you applied to an insurance company that asks you to pay to take out medical insurance, look for other specialists. Fortunately, the competition in the market is big, ”Tatiana advises.


Insurance agent Tatyana Sokol advises to stop working with those insurance companies that take money for the selection of insurance. Photo: from the personal archive

For lack of insurance, a fine is imposed. In 2014, he was $ 95 from one family member, this year has grown to $ 400, and by 2016, the fine will increase to $ 695 from one person or 2,5% of taxable income (depending on which number is higher). From the tax penalty will be exempt in the event that it exceeds 8% annual income. In addition, the size of the fine today can not exceed the cost of the cheapest insurance plan offered in your state.

In the states of Alabama, Wyoming and Montana, laws have been passed that block the use of a federal tax penalty for lack of medical insurance. But considering that federal law takes precedence over state law, it is not entirely clear whether it will be possible to avoid punishment.

Where to begin

In the US, many employers provide health insurance. Just keep in mind that there are nuances here: the employer is not always ready to pay your insurance premiums in full. You still have to pay for insurance, but cheaper than if you buy it yourself - part of the cost will still be covered by the company-employer. Specify whether the employer is not planning to deduct your part of insurance premiums from your salary. If the employer’s insurance plan does not suit you, you can apply for insurance yourself.

Alex Pshenichny, an employee of a law firm in Sacramento, is partially paid by the employer. “The employer pays 80% of the cost of my insurance and 30% of the cost of insurance for my wife. In total, this is $ 400 for two per month. In addition, the employer pays my ophthalmological insurance in full. In that year, I checked my eyesight twice and changed lenses for free, ”says Wheat.

What should those who need to take out insurance do

On the federal website Insurance plans of various companies are put together, and you can choose the most suitable one. After processing your data, you will be told whether you are eligible for free insurance, are there discounts for market plans for you, and if so, in what amount. Then you will need to compare all insurance plans and choose the most suitable. serves most states, but 14 has its own sites. Therefore, if you live, for example, in New York, then you will automatically be redirected to local sitewhere you can view and compare different insurance plans and find out if you can count on financial assistance from the state.

Programs for the needy

Since in some states the federal insurance program is allowed to supplement or change, offers in different parts of the United States may vary.

For example, in California created a state program Covered CA - An analogue of the federal insurance program. After processing the data about you, the system determines what insurance coverage you are entitled to. Medi-Cal is free coverage for low-income people in California, with an income of just over $ 16 000 per year. In other states, it has a different name.

And low-income residents of New York who do not qualify for free insurance offer a new program for 2016 year. Essential Plan. This is a government program with minimal monthly payments - only $ 20. For families with incomes below 138% federal poverty level, the program is free. A person who has an Essential Plan can afford regular check-ups, visits to a specialist, and payment for prescription drugs.

For information: 138% Federal Poverty Level in 2016 - this is $ 16 242 per year per person, $ 21 983 - for a family of two people, $ 27 724 - for a family of three people, $ 33 465 - for a family of four, and so on.

When to buy insurance

The selection and purchase period for the insurance policy on 2016 began on November 15 and will be open until December 15 of 2015. If during this month you have not changed your insurance plan, your insurance is automatically renewed for a year in the same form. And you can change the plan only in a special case (for example, relocation, birth of a child, wedding, death of a spouse - that is, a change in the number of family members).

REMEMBER: you can get insurance throughout the year in the following cases:

- If your family has an income that does not exceed $ 16 242 per year, you can get insurance at any time during the year and receive it within a month.

- If you want to insure children younger than 19 years.

- If you are entitled to free insurance and you meet the requirements.

- If you are the so-called new resident, you have received the status of a legal resident of the United States.

- If you live in New York and you are entitled to Essential Plan (withsee above).

How to understand the plans

If you do not fit under any state program, then you can at a special Online find out how much ordinary insurance will cost you. The price of medical insurance for an adult in the United States can vary greatly and range from $ 150 to $ 500 or more per month. The cost of your insurance will depend not only on the type of insurance plan, but also on the state, county, medical history, income, age and many other factors.

The next step is to understand the difference between insurance plans.

There are several types of insurance. The type of doctors and hospitals you will be able to use will depend on which type you choose.

  1. HMO (Health Maintenance Organization): You can visit those hospitals that have entered into an agreement with the HMO (this does not apply to emergency care). You can contact specialists only in the direction from your therapist. Plus HMO - in low insurance premiums.
  2. EPO (Exclusive Provider Organization) differs from the HMO higher fees, as well as the opportunity to contact specialists without a referral. You will only have to visit those hospitals that have entered into an agreement with the EPO (this does not apply to emergency care).
  3. PPO (Preferred Provider Organization) - A plan with the highest cost of insurance, but also with the widest possibilities. You can be treated in any institution, with any doctors. If the doctor also entered into an agreement with the RRO, then you will be offered more favorable conditions. PPO also does not require referral to specialists. PPO has the widest network of doctors.
  4. POS (Point of Service Plan) puts the following condition: you can go to specialists only with the direction of the therapist, but this specialist can receive outside the network.

Olga Polovneva from Davis Californian, I have already felt the benefit of insurance and feel how important it is to choose the right type: “My insurance costs $ 500, this is a type of NMO, and I can only visit doctors at one clinic. For a visit to the therapist, I pay $ 20. But I have skin problems, and I need to go to a dermatologist several times a year (I pay $ 35 for this). With my insurance, you can get to a dermatologist only in the direction. So it turns out that every time I have to sign up for a therapist and pay $ 20. But this plan is still beneficial to me because the ointment that the dermatologist prescribes is on the list of covered drugs. I pay for it only $ 7 instead of $ 150 »

TIP: еIf you suffer from chronic diseases, then choosing a health insurance plan, be sure to check the list of covered drugs to find out if your medications are in your diet and how much you will need to pay for them.

In order to be well oriented when choosing insurance, it is also desirable to understand several terms:

premium - the monthly amount to pay for insurance;

deductible - The amount you have to pay for medical services before your insurance will cover them;

co-payment - a fixed amount of surcharge for a visit to the doctor, medical services or medications;

co-insurance - Covering the costs of the insurance company and you as a percentage, starting after the full payment of the “deductible”;

out-of-pocket limit - the maximum amount spent out of your pocket during the year, upon reaching which the insurance begins to cover your expenses in 100 percent size.

Depending on the size of the percentage of coverage of medical expenses, many insurance plans are divided into several major ones:

Bronze (insurance company pays up to 60%),

silver (insurance company pays up to 70%),

gold (insurance company pays up to 80%),

platinum (insurance company pays up to 90%).

Depending on the level of the plan, the cost of insurance rises and the amount you have to pay for medical services, a visit to a doctor or medication decreases.

Consider: whatever plan or type of insurance you choose, and in whatever state you live, dental and ophthalmologic insurance must be purchased separately.

How to survive without insurance

Some prefer not to buy insurance, but pay a fine at the end of the year. At the same time, getting medical aid if you are sick is difficult, but quite realistic. Otherwise, the statistics would not say that every fifth US citizen either lives completely without insurance (in America there are more than 45 millions of uninsured people), or has such a primitive insurance (there are more than 20 millions) that he must pay extra for his initial and elementary visit to the doctor pocket.

Совет №1. You should always be wondering if there is a possibility to pay for a visit, analysis, a transaction not in insurance, but in cash. So, in many clinics you can take a blood test by paying in cash.

California physician Ganna Rubinstein gives an example: "If you pay in cash, a blood test will cost $ 98, and under insurance more than $ 400."

Tip # 2. It is necessary to find out the addresses and phone numbers of “walk-in” clinics (community hospitals) that are in your city. These clinics are a kind of district clinics to which we are accustomed from childhood. Total in America around 11000 "walk-in" clinics. The doctors there prescribe medications and referrals for tests - in general, they provide the same services as the family doctor who takes a patient with insurance. The principal difference is that you can only get to the doctor in the queue. Sometimes you need to wait for 15-20 minutes, and sometimes you can spend several hours in a queue. And most importantly - the doctors in such clinics work in shifts, that is, there is no guarantee that, coming a second time, you will go to the same specialist. In this case, prices for services they have enough lifting. For example - the cost of services in the largest network of "walk-in" clinics MinuteClinic: A visit with bronchitis or a minor burn will cost $ 79-99, adult vaccination against hepatitis A or B - in $ 140.

Sarah Hudson from Florida shared her experience: “My daughter needed the help of a psychologist. We just arrived in Orlando from Russia, and I had no idea how everything works here. The first piece of advice they gave me was to find a “walk-in” clinic. A visit to a psychologist cost only $ 20. I really liked how they treated us at the clinic, how they met us, realizing that my English was really bad. When a couple of months later I got sick myself, and I still had no insurance, a visit to the doctor cost me $ 39. "

Find a list of "walk-in" clinics in your city can be, for example, On this Onlineby typing in the search string "walk-in clinics". In addition to the address, find out the time of work (some work from Monday to Friday, others - seven days a week and around the clock) and working conditions with patients. In many hospitals, they don’t take money for a return visit at all if you once again went to the doctor during 36 hours since the first visit.

Read also on ForumDaily:

How to avoid a fine if there is no health insurance

The cost of medicine in the United States over 15 years has tripled

In the United States began to calculate those who cheat with medical insurance

Who can get Medicare and Medicaid

How to reduce the bill for treatment in an American hospital

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