Health insurance and medical care in the United States is by and large a private business. Coming from the UK, that means you are in for a huge adjustment, not only in the fact that you have to get private health insurance, but also in the way some of the insurance operates.
Let's start with the most important point:
You need health insurance.
Cash and carry is really not an option in the US, where one day in the hospital can easily run $4,000, even for the simplest of treatments. A surgery can be $25,000-$50,000, and a major illness would break the bank of all but the wealthiest individuals. One British expat on this forum who put off sending in the forms and put it off was suddenly hit with a disaster when her husband fell off a ladder and had to be airlifted by helicopter to a hospital where they spent days in the Intensive Care Unit. After only 3 or 4 days they had bills of $450,000.
But now that we've stated that point, let's talk about how insurance generally works in the US. This is a very ROUGH outline of some of the major points, and you should be sure to look into the specifics of your company's offerings and the insurance policy itself.
Insurance -- Costs
Q: How much is this going to cost me?
A: We haven't a clue.
Honestly, there is simply no way we can determine that number. We can give you the following range, based on some member's individual and ANECDOTAL experiences, but each insurance plan is catered and priced according to the specific circumstances of in the entity buying it (usually your company) and the specifics of the individual using it (i.e. you).
So, with that said, here are some anecdotal numbers for monthly premiums:
$250--basic coverage for a 24-year-old non-smoker (with a high deductible)
$600--good coverage for a 30-year-old married couple.
$1500--very good coverage for a 40-year old couple with two children
$1500--a 65-year-old retiree who is not eligible for Medicare
$2200--a 75-year-old with a history of high blood pressure not eligible for Medicare.
You--somewhere between $250 and $2,200 a month. And with that said, it is also important to note that some companies require you to pay this IN FULL and some companies will actually pay this ENTIRELY as part of their benefits package. Most folks seem to have a bit of a mix, with the company paying part and the individual paying part (along with paying co-pays and deductibles every time they use the service)
So what factors go into determining the final cost:
What state are you living in?
What city are you living in?
Who is your employer?
Are you buying an individual (i.e. non-group) plan?
How much can you afford in annual deductibles?
What is your history of cancer, obesity, smoking, heart disease, etc?
What is your parent's history of cancer, obesity, high blood pressure, etc?
How much exercise do you do every week?
What is your income?
Are you married?
Do you have children?
What is your credit rating (USA)?
What pre-existing medical conditions do you have?
This is not a full list nor is every question asked in every case, but it gives you an example of how many various factors go into determining the final cost.
Obamacare - The Affordable Care Act.
Let's make one thing clear from the start:
Obamacare is NOT the NHS.
To people coming from the UK hearing about the battles in the USA over "socialist" medical plans in the USA under "Obamacare" they have started to think that it must be something similar to what they have experienced, a single-payer comprehensive system like the NHS. This is not the case.
Obamacare is a series of changes to the way US private health care insurance is bought, sold, and regulated. The easiest way to think of it is a marketplace for a variety of private insurance companies to offer you different types of insurance, along with some subsidies to purchase insurance if you fall within specific income levels. The rollout of the ACA is ongoing and not all elements have taken effect such that this section of the wiki will be a work in progress for the next few years.
Insurance -- How to Purchase.
The majority of people get their health from their employer. This insurance is usually fully paid, partially paid, or you pay for it yourself. Your employer often strikes a deal with a specific company to get a 'group benefit' meaning the plan is slightly cheaper than if you were buying directly from the insurance company. Some employers offer a buffet option where they have 10 or 20 different plans and you pick the one you feel will be most appropriate.
Not all insurance is alike. Some plans have high premiums (monthly payments) but low deductibles (out of pocket expenses you are responsible for). Other plans have high copays (fees you pay each time you go to the doctor) and others cover (or do not cover) certain things. Some are part of an HMO that allows you to go to certain doctors who are 'in network' and charges you more if you go 'out of network'. Some insurance has policy maximums (the total they will pay over your lifespan) and others have a percentage formula where they pay 90% of expenses over such and such amount, 80% over such and such, etc.
Self- and unemployed individuals can purchase insurance directly from the insurance company, but generally for a higher rate then they would if they were part of a 'group' plan.
Under the Affordable Care Act / Obamacare, there are not health insurance "exchanges" running online throughout most of the United States where you can easily put in your details and see what sort of plans will be available to you. As you review these plans, there are several variations that you will need to review that can affect your monthly payment (premiums) or your annual payment (deductible) along with other costs.
Terms you should note:
Group Plan -- A plan that is arranged by a group (i.e. your employer) and offered to the members (i.e. employees), sometimes at a discounted rate. The majority of group plans are from employers, but some organizations (alumni groups, interest groups, labor unions, etc) may band together and offer 'group' insurance.
Individual Plan -- A plan you purchase directly from an insurance company or broker. There are some important differences between group and individual plans relating to pre-existing conditions.
Premiums--Periodic payment for insurance. (This may be monthly or it may be "per pay period" - being paid every 2 weeks is common in the US)
Deductible--Amount you pay before insurance starts to pay.
Co-pay--Amount you pay the doctor for each visit, usually $20 or so
HMO--Health Maintenance Organization. A system of screening nurses, doctors and hospitals working together under a certain procedure.
PPO--Preferred Provider Organization. A system where you pick a local doctor and hospital to use who negotiates a decent price with the insurance company.
In-network--A health care provider who has worked out a billing and fee arrangement with your insurance provider.
Out of network--A health care provider who has NOT worked out a billing and fee arrangement with your insurance provider.
Pre-existing conditions and the NHS
A pre-existing condition is something you are currently being treated for under the guidance of a doctor. US insurance companies can REFUSE to insure you if you have a pre-existing condition, or require a waiting period before your coverage commences, with a few important to know exceptions.
If you have "credible coverage" by an insurance company, or by a national insurance system of another country (i.e. the NHS), pre-existing conditions are covered if:
a) you are joining a group, not individual plan.
b) you join the new insurance within 62 days of your old insurance ending. In the case of the NHS, that means you need to have insurance within 62 days of arriving in the USA.
Under 'Obamacare' there will be a ban on pre-existing conditions being a reason for denial. However, this has not taken effect and it is likely that a court argument on this provision may delay the implementation for many years.
Some insurance companies in the USA will request a letter stating "I was covered by the NHS from this month to this month." Others basically assume since you are from the UK you were covered. You'll need to sort this out with your agent when you are offered an insurance policy.
Insurance - Using
GP, aka Family Doctor
When you get an insurance plan, you'll be issued a card with your number and the insurance company's phone number. It's probably a good idea to put this in your wallet or purse, and maybe even one in your car with your car insurance and registration. You'll often have to present this card when you go to the doctor, and it is helpful if they find you on the street knocked out.
If you want to go to a doctor, your choices are probably based on your insurance plan. First you should ask for a 'doctor's list' from the insurance company and they'll give you the names and details of the doctors in your area that accept your insurance plan. You don't have to go to the doctor's on the list (i.e. you can go 'out of network') but you can expect to pay more with a doctor who isn't part of your plan. In addition, you may have to pay first and then seek a reimbursement from the insurance company if you go out of network.
Once you have a few doctors in mind, you can Google them or look in the yellow pages phone book for a 'Doctor Locator' number. These services will tell you more about the doctor. Is he a 'sole practioner' or part of a group of doctors. Does he speak English / Spanish / Chinese? What is his bedside manner, gruff and assertive or calm and understanding. Etc.
When you have a doctor in mind, just call them up. Tell them you are a new patient and you would like to be seen for XYZ. They'll make an appointment (usually within a few days) and you head on over. In a "I'm sick now" situation most offices often have time for 'walk-ins' early in the morning or late in the afternoon.
Your first visit will be quite a bit of paperwork. Have you had the measles, are you allergic to this, where can we contact you, etc. Budget about 15 minutes extra to fill in this stuff. You'll pay the copay required by your insurance (cash or credit card) and then go to the waiting room to read 6 month old magazines.
Anyway, then the doctor will see you, say you have this, need this medicine or treatment, etc.
Generally, that's it. The doctor's office will submit the bill directly to the insurance company (provided you are in-network). If the insurance company says 'we don't pay for that' then you'll get an explanation from the insurance company and a bill directly from the doctor. Call the insurance company and argue (it often works) and they might end up paying for it anyway. If not, pay the doctor the remainder (but keep the receipt for tax purposes).
Prescriptions
You'll get your prescription from the doctor and walk out. Take the prescription to Walmart or a drug store and you'll get your medicine in just a bit. Again their may be a copay at this stage, or it may be free. You really never know. You should ask the doctor if a 'generic' is available (a non-brand version of the drug with the same effect). If you go with a big chain, like Walmart or Safeway or Rite Aid, etc, your records will be added to their system and available at any store in the country (helpful if you travel a bit). If you are uninsured consider a bigger chain like Walmart and tell them you have no insurance. They have a program to provide medications at a lower rate to those without insurance.
Not every pharmacy carries every generic, so try medtipster.com. Enter your drug name and zipcode and the site will find a pharmacy in your area that offers the generic you need.
Specialists
Now let's say the doctor say you need to see a specialist who deals in 'Diseases of the South Pacific' or something. He will give you a 'referral' (i.e. a note) that you will need for the insurance and then you'll go and make an appointment with a specialist. Again, depending on your insurance, this may be an in network or out of network thing. You make an appointment with them, get prescriptions and billing much like that of a GP.
Emergency
By law, a hospital cannot refuse to treat an emergency patient due to their ability (or inability) to pay. If you get hit by a truck and are brought in bleeding, you'll be rushed to the ER (emergency room) and treated long before anyone even asks who your insurance company is. Just call 911 and get in an ambulance and forget about the paperwork for now.
After you are taken out of the ER and admitted to recovery in the hospital, then the money folks will come around asking about insurance. In some cases, you may need to call (or have a family member call) the insurance company to say 'I've been taken to XYZ hospital'. If that hospital is out of network, then it is possible, once stable and better, that they would transition you to another hospital they work with. Some insurance companies don't go that far.
NOTE: Just because they
treat you without you having insurance doesn't mean they are not going to
bill you for their services. You'll get patched up to the point you can crawl out of the hospital, but you should still expect a bill--a major bill--to come in the mail. Failure to pay this debt will result in the credit collection process, etc coming after you.
Problems you may have with your insurance.
At a user level, there are many things you should watch out for with your insurance. Reading the fine print of the policy is ESSENTIAL to know just what is and is not covered. You also need to be willing to stand up to the insurance company.
Insurance companies love to deny claims saying 'this isn't covered' or 'this wasn't medically necessary' or 'this is experimental'. You'll need to argue back with them and may even need to have your doctor get involved (and doctor's office, by and large, are no friend of the insurance companies).
Companies may also try to carve out certain things that they will not pay for. We don't do eye glasses. We don't do dental. We don't do mental health, we don't do cancer. The list can be long. You'll need to check your fine print to see what is and is not on the list.
Insurance companies also make mistakes. A hospital bill for a two day visit can easily run 10 pages long. Easily. You'll have to go through line by line and see that everything was properly billed, and you can be certain that sometimes the insurance companies mess things up when they are doing that as well.
Problems with Health Care in the USA
If you just read through that, it all seems pretty easy. So what is the big problem I hear about on TV and read about in the papers?
To be honest, anyone who tells you 'I know what the problem is with health care' if probably full of it. It is an incredibly complicated machine in which many little aspects have been off kilter and affecting many other aspects. It was not built as one core unit, but rather is a collection of competing interests often working against one another. I'll only list a few here as an example of how the problems that do exist come back to haunt the whole industry.
The first, and probably the most common problem you will hear about is the uninsured. About 15% of Americans do not have insurance. A much much higher percentage do not have full coverage and are getting by with only the basic coverage, living in fear of a 'big calamity'. Many of these are poor and or the elderly, two groups who often use or need to use health care more frequently.
A second problem is price. Insurance for a family of four, if the employer does not contribute anything (which is pretty common) can easily run over $1,000 a MONTH. A healthy 21 year old can probably get a policy for $200 or $300 a month, but when you are having kids and whatnot it gets quite a bit more expensive.
A retiree without an employer or some form of coverage can expect $1,000 a month in premiums MINIMUM. (bolded because we get asked that often).
This leads to situations where people put off health care until little problems become even bigger. Some poor people goto the extremely expensive ER to get treatment for a simple scratch or a headache because they cannot afford a doctor's visit. Of course they cannot pay for the ER. Others have what could have been treated with a medium priced treatment early, but is now an expensive and costly surgery later on. The patient cannot possibly afford to pay this and goes bankrupt, leaving the hospital out of money and passing the loss onto their other paying patients, thus raising the price for their services. And on. And on. And on.
Another problem is that doctors are under threat of legal proceedings should they misdiagnose, leading them to purchase costly medical malpractice insurance to fend off the lawyers. The cost of the insurance is worked into everything from a doctor's visit to a blood test.
There is also a problem with drug companies make huge profits. These companies invest huge amounts of money to R&D drugs, but cannot recover this from European public health organizations which only pay a fixed price for certain medication, and who have some nations disregard their patents and produce knock off pirated drugs. Guess who gets stuck with this added expense and helps keep the profit levels high?
And so on and so on. Many of these structural problems are extensive, deeply ingrained in the system, and nearly impossible to remove.
National Health Care in the USA
Believe it or not, the US does have some public health care options. In fact, a large swath of Americans are on "public health insurance" despite claims that it is "socialism". There are two federal programs, often administered by the individual states, to provide some form of medical treatment to Americans. Medicaid and Medicare.
Medi-caid is for the poor. Medi-care is for the elderly.
And it is likely that you, as an expat, cannot get either.
As part of the Welfare Reform Law under President Bill Clinton, a new requirement that recent immigrants would have to wait FIVE (5) YEARS after they get their Green Card before they would be eligible for Medicaid or Medicare. This means the reality is with a few years often needed just to get the green card, the wait can me 6-8 years after you arrive off the boat before you are eligible for these public health programs.
However, individual states (who are the ones who administer the nuts and bolts of the public health programs) are able to write their own laws. Depending on the state, Medicaid is available, in some circumstances, to individuals regardless of their immigration status. For example in California, Medi-cal (the California implementation of Medi-caid) is available in some circumstances to legal visitors and illegal visitors alike. In almost all states low income women can get pregnancy assistance. However, in some states they follow the federal prohibition to the letter and there is no option.
Medi-care is something Americans contribute to on an ongoing basis while they are working. When they reach a certain age, it is available to them as a primary insurance system, though they often purchase a supplemental policy to cover other situations. An expat moving to the US has a rough time getting Medicare. While they can 'buy in' to the system (i.e. make payments to catch up with Americans who have been paying all their lives) they cannot do so until FIVE YEARS after they are given a Green Card.
A Cultural Note:
Chances are you grew up with the NHS. More than likely your parents grew up with it as well (and in some case, maybe even your grandparents). It's been there and it is just how things are done and quite frankly, you cannot imagine anything different.
The same is true for Americans. And this is an important point.
Many Americans believe that health insurance is something you simply have to buy to be a responsible member of society. It is something YOU pay for out of YOUR money to cover YOUR situation. And it has always been that way. Their parents did it, their grandparents did it, etc. If you smoke, drink, or are obese, you should pay more, because those are the choices you make and you should deal with them. If you live a healthy life, don't drive too fast, etc, you should pay less, because you are less of a risk. But it is something that you are responsible for handling--not the government. There is a very large portion of the American public that believes this way. It's part of the culture of self-sufficiency and lack of reliance on government for basic services.
So the shock and horror that you may be feeling that it is NOT being provided is often matched by the shock and horror that some Americans feel that you are 'entitled' to such a thing. Some Americans think it is simply
offensive to expect them, through their tax dollars, to pay for your health care. While the political winds are blowing toward a more managed system (and growing numbers support that, especially as costs grow higher and higher), it is important to note this basic philosophical position.
Basically, don't expect a full-fledged NHS anytime in the next decade to appear in the US, and don't plan on any major medical procedure if you don't have some form of private health insurance.
Common Insurance Providers
This list is by no way fully comprehensive of all the providers out there, nor does it consider any regional state variations, but they are the more common companies which you'll have cover offered from by an employer.
Temporary Insurance Providers
These are programs designed for new immigrants to the US. They are more restrictive (or cover less) than full medical plans, and most are only valid for up to the first few years on entering the US. If you don't have medical insurance upon arrival then this may be a useful stop gap until full coverage starts. Read the Ts&Cs carefully, noting what is and isn't covered. Check that they are "prior credible coverage" so that when you go on to a full program, you are covered for all aspects without a time gap in cover.
Aug 30th 2023, 2:45 pm - Wikipost
Re: Health insurance: Master Wiki Thread
