jenbug

Hi,

I have some (possibly fairly obvious!) questions about the medical system here. We recently moved to Wisconisn and we have medical insurance but I'm feeling a bit clueless about how the whole thing works!
How do you get a GP here? Do you have to pay for visits to the GP? Someone at the gym was telling me that I should have a general medical check - is that something you have to pay for? And finally, what happens if you have to go to the Emergency Room - do you need to carry your policy number with at all times?
Would really appreciate information on this - thanks!

lisa67

Everything depends on what type of health coverage you have !
we use a general doctor (pcp) for veerything whereas others see a pediatrician for their kids, a gyno for girly stuff, dermatologist etc. etc.
I have been lucky enough to find good doctors in the 2 places where we have lived and so just use them unless they recommend a specialist.

So depending on your coverage you usually have to pay for your doctors visit (our is $25 per visit) ...check your covereage and look for "co-pay" that should tell you, usually as a percentage, how much you have to pay for your medical care (I think ours is 20%)
If you need to go to the ER they will ask for your medical card (with the policy number on it) before they see you..take this card with you everywhere !! If you have kids you will need to give this info. to school and usually on waiver forms for activities (gymnastics etc)

As for finding a good doctor...ask around is probably the best advice. Your neighbours might have suggestions, or co workers.

I hope this helps and feel free to pm me if you need to. It can be very confusing ! (It's also a similar thing with dentists..check if you have dental coverage) some health coverage includes opticians, chiropractors etc.

lisa67

Oh, forgot to mention that you need to check to see if your med. coverage covers pescriptions. Some do, some don't. We used to have a scheme that covered everything. Now we have a separate one for pescriptions.

penguinsix

Hi

First, it varies a lot with the policies that are out there, so let me start by making some general statements and then you can get some ideas and check around. Some policies have high deductibles (your cost) but low premiums (monthly expense) and some are the the opposite. Some are totally paid by you and some are totally paid by the employer (getting fewer and far between).

Most people have insurance or an HMO (Health Maintenance Organization) that requires them to pick a 'primary doctor'. This is a GP in your area, and usually they have to be 'in network' with your insurance provider. This means the insurance company and the doctor have reached an agreement on how much things costs, how to bill, etc. Ask for a 'doctor's list' from your health insurance company and they'll give you the names.

You can then check out some more info on them by googling them--some hospitals will list doctors affiliated with them and even give you a bit more info, like do they speak Spanish, what is their bedside manner, who is their sub (when they are on vacation). You pick this one, tell your insurance company, and this is your primary care person.

When you want to go, ring up the doctors office and make an appointment. There will usually be a 'copay' which is a small amount ($10-$25) that you pay and the insurance covers the remainder. If there is a prescription you pick a pharmacy nearby (or a Walmart) and get it filled. Often you should ask if there is a 'generic' that is available as that will cost far less than a name brand drug (but do the same thing). Usually you'll have a co-pay with the drugs, or pay for it in total, or have it cover (depends on your insurance).

If you have a major issue, requiring a specialist, you'll get a 'referral' (a note) from your local guy who sends you to a specialist. Again a copay, and it also helps if the specialist is in network.

If you need to go to the hospital, then you'll have a copay and you might also start talking about deductibles--i.e. the amount you have to pay before the insurance kicks in. It could be $500 or $5000, depends on what coverage you have. You are responsible for the first $XX and then insurance covers the rest UP TO A POINT (this is where many people get tripped up). After say $1,000,000 in coverage, some insurance companies say 'ok, you're done' and then you're liable. Can really suck.

If you have to go to the emergency room--GO. By law an emergency room cannot turn away someone based on ability to pay (or not pay) (this is actually part of the problem as people without insurance go to the emergency room for headaches and other ailments better and cheaper handled by local doctors). Usually you'll have 24-48 hours to notify your insurance company that you have arrived.

As a general guideline, carry the insurance card in your wallet with you. It's a really good thing to have. They'll send it to you when you get your policy started.

But for now--READ THE FINE PRINT. What is your copay. What is your deductible. What is your maximum. What is your prescription coverage. Dental, Eyes? Mental? Get a good reading on what is covered (and how much your premium is each month) so you don't find out later when it is too late.

movingtomass

Quick question with regards to the above - once you make a claim (ie go to see your GP for a certain condition, visit the ER), does your premium then increase?

MsElui

from what i can tell - us ladies go and see the doc (usually but not always an OB/GYN) once a year for a well woman check. This covers smears and mammograms etc if they are needed at your age etc. check what you are covered by with your insurance beforehand so you can say yes or no to any optional tests they may offer.

Then if you have any issues at other times that are non emergency then you book an appointment with a family or general practice doctor. I tried to register with one in advance when we arrived in the US (like you would in the uk) but they were not interested and just wanted to deal with either of us as and when we needed an appointment. so my husband has been when his asthma stuff needed sorting and i have yet to use a general doc. I have seen an OB/GYN and been billed my $10 co-pay and also sent a $10 copay from the lab who did my blood tests (taken at the same doctors appointment).

Always check that any non emergency appointment (ie OB/GYN, General doctor, Dentist etc) is on your insurance company network as this restricts the amount you have to pay. If you use a non-network provider then your co-pay bit can be much larger. We are with Cigna International so I always just check that is accepted by the doctor when making the first phone call.

Tracym

Not generally.

To break types of insurance up further - you can have an individual plan, or be part of a group plan (the latter generally through work). Certainly in a group plan, the answer to your question is no

Some more notes to the OP... there are generally three types of insurance:

Major medical - rare, you can go to whatever doctors you like
PPO - You can go to whatever doctors you like, but it's cheaper "in-network"
HMO - you need one primary care doctor, who must refer you to specialists - all must be "in-network"

Your insurance company should provide you with a list, or online search, of in-network providers if that is required

If a doctor you want isn't in the network, you can ask for them to join, and they often will

As far as costs, there are basically 4 kinds of costs:

Premium
Co-pays - fixed amounts for things like doctor visits and prescriptions
Co-insurance - a percentage of other medical bills you have to pay
Deductible (often an amount that must be paid before insurance pays out other than for doctor visits)

All the details should be in the insurance policy. If it's a policy through work, a human resources person at the company ought to be able to help explain it.

Generally, there will be some cost to any kind of medical care you receive (co-insurance or co-pay).

I believe there is generally a limit per year to total out-of-pocket expenses though.

Bob

What kind of insurance? HMO or PPO?

PPO generally means you can see any doctor and specialist without a referral, and HMO generally you have to be registered with a PCP (GP to you) and then get referred for anything special.

Post coverage will offer a medical check up once a year, might as well get one done.

Co-pay, that's how much you'll pay each time you see your doctor, usually around the $20 mark.

You'll have one for prescriptions and visiting the ER, though that might be waived if your admitted overnight, again, read small print. You might have one for using an ambulance, check the small print on ambulance usuage.

You might have an annual deductible, how much you'll have to pay before insurance kicks in. You might have that as a total sum, or broken down for certain things, such as $500 for per hospital stay, for physio, etc.

Check to see if there is an annual or lifetime pay out limit on the policy....have a look at if you can get partial reimbursement for joining a gym, weight loss classes, massage, acupuncture etc.

NC Penguin

If you already have the coverage, it's likely you can check exactly what's covered and your co-pay, in and out of network percentage coverage, etc. on the health insurance provider's website.

You should carry your health insurance card (provided by the insurer) at all times. It's pretty much the first thing you'll be asked to show when you go to a doctor and probably the ER (fortunately yet to go to one as a patient).

augigi

As a guide, I have HMO coverage. IF I go to the GP for a routine checkup, it costs me $5 copay. If I go there sick for treatment, it's a $15 copay. If I go to a specialist, it's $25 (curiously enough, the chiropractor counts as a specialist and costs more than the GP/PCP!).

I just went and had a first visit with the GP (new pt visit). She did bloods and I got a bill for $67. I have a $200 annual deductible, so I have to pay the first $200 before insurance kicks in. I recently had an xray of my ankle - $10 copay. Then I had to get an M-R-I of my ankle - $60 copay. (for some reason, it censors M-R-I without the hyphens!)

I also had the option to put money in a Flexible Spending Account, which is basically money you put aside from your pay, pre-tax, which you can then pay your copays/deductibles with. I am going to do much more next year - this year I allocated $250 and I've already hit that with the above plus some PT visits for my foot.
===================

Do a search, I posted a similar question before I moved over about how it works and got some good responses then. The best thing to do is get your health insurance policy document and check it out in detail. Really, once you start using it things become less confusing though - it's a whole other language!

Bluegrass Lass

Only thing I would add here is that you should call the doctor that you select and make sure they are taking new patients. Doctors can decide that they are seeing enough people in their practice, and no longer allow new patients. So before notifiying the insurance company of your choice, call the dr's office.

As others stated, you do not register for a doctor here. If/when you are sick, then you select a doctor (call them first), and then you may need to call your ins. company to tell them your choice of primary care physician.


Also wanted to add, that in most areas (that I'm aware of) going to an ER is not your only choice. If you cut yourself, or you feel like you're coming down with something, then you can visit an Immediate Care Center, or an Urgent Care Center (they can go by either name). Typically, these are covered the same way that a normal doctor's visit would be, and you don't need an appointment, you just walk-in. They are quicker to get in and out of than an ER, and will cost you less. They even do broken bones. Heck, our local one even has a CT and M-R-I scan equipment

Duncan Roberts

If you have private insurance it's very possible depending on why you see them. If it's something like a broken leg or tonsillitis or something like that then probably not. If it's a chronic condition or something long term like cancer, diabetes, those types of thing then it is very likely. However, certain states have their own rules about that.

If you have group insurance through an employer, the same is true but generally the price goes up the same amount for everyone and it's not a whole lot because the risk is split between a lot of people, although prices can jump a lot. The premiums are based on everyone in the group so if you are in a group that is historically young, mainly males in good health your premium will be lower than in a group that is historically older people in bad health.

In the last couple of years between my wife and I we've had probably close to or over $50,000 worth of claims. The group premiums have gone up but by around $15 or so each year for all employees on the plan we chose.

Rete

If you weren't given one, then ask HR for the booklet that lists the doctors, medical centers and hospitals and labs that will accept your hospitalization plan. You can then choose your physician from there. Many people go by referral from friends and co-workers. I did that and hated the doctor a friend recommended. However, because it was a fairly large medical practice with several doctors I just transferred over to one that I did like.

You need to carry your hospitalization card with you at all times. It will be asked for when you do go to the doctors and when you go to the hospital for any kind of medical care or test. Most insurances have a co-pay attached to them even if they are not HMOs.

I would strongly suggest that you make an appointment with your HR person and have them explain to you how your medical insurance works. They are familiar with the policy and coverage.

PPOs are different from HMOs so there is a world of difference in the matter of usage.

jenbug

Wow! Thanks everyone – this has been totally invaluable. I had no idea!

We’re lucky in that my partners company have organized and paid for our policy for us. However, they’re quite new to the whole international relocation thing and have been fairly disorganised in several areas (they are a UK employer setting up a US branch of their business). Most markedly, we didn’t even have health cover for the first month we were over here until we found out and caused a big fuss!

All they have given us is a scanned copy of the front of the policy so all the information about carrying a medical card was new to us. We’ve just called the provider and asked them to send us a full copy of the policy and medical cards.

We are insured with worldwide cover from Allianz, a UK company. From speaking to the lady on the phone this morning, it would appear that this may work slightly differently to some of the US policies but I’ll be able to get my head round this once the paperwork appears. She told us that we have an unrestricted choice of doctors. At the moment, I can’t tell from the certificate that we have whether we are HMO, PPO (if this does apply to this policy) or what our co-pay or deductible is. It looks like we have dental coverage but I’m not sure about anything else.

We’ve been here a couple of months and I’ve been putting off finding a doctor or getting any medical checks done. Once we get this info I’m going to spring into action on this but for now, I’ll concentrate on getting the policy and going through the fine-print.

Thanks so much – the advice that you’ve given me has been really useful. I didn’t even know that we were missing the information that we needed! Thanks!

Duncan Roberts

OK, there are a couple of things you say throw red flags. I don't want to say this happens all the time but often when you have an insurance policy from a company outside the US, you have to pay upfront medical costs and get reimbursed. You may also find the reimbursement isn't that high.

I would strongly suggest really reading through and understanding the policy and then if it's not great, really pushing hard to get a good US based one.