A Beginner’s Guide to Health Insurance in the US

Migrant Resources

A Beginner’s Guide to Health Insurance in the US

Stay informed so you can stay covered

When you move to a new country, it can feel like everything is completely different than the way you’re used to doing things. For people moving to the United States, perhaps the biggest change we encounter is health insurance.

Unlike many countries, the US does not have universal health care. The Affordable Care Act (ACA), or Obamacare, was a move in that direction, but it still follows the model that individual health insurance companies offer different plans at varying prices. You choose the best plan for you and your family at a price you are comfortable with. It all depends on what medical needs you have.

But how do you get insurance? What’s the difference between plans? Don’t be intimidated. We break it all down in this easy guide to help you navigate health insurance in the US:

How does health insurance work?

Those with health insurance receive a card in the mail with information about their plan, including their group number. The group number can be found on your insurance card and is unique to your company. Therefore, everyone in your company will have the same group number.

When you go to the doctor or a pharmacy, they will ask to see your card so they know how to bill your visit and any prescriptions. They will only need to do this once—they’ll keep the information for any future visits. It’s important to let your doctor or pharmacist know if you have new insurance.

The doctor will typically charge you a copay, a reduced amount since you have insurance. The prescription will also be a lower amount. If it’s not covered by your insurance, you pay the full amount or the difference. Sometimes you will get a bill later for services that your insurance does not cover.

Note:

Medical health insurance does not include dental or vision insurance. You will need separate insurance plans for those.

How do I get health insurance?

According to the ACA, employers who have more than 50 full-time employees are required to provide health insurance. If your company meets this standard, then you should be able to join the company’s health insurance plan. They may also cover all or part of your spouse or children’s health insurance. 

When couples work for different companies, they can opt to use their own company’s health insurance, or they can compare which company offers the better plan and both sign up for that.

If you work at a smaller company, are a part-time employee, or self-employed, you can get health insurance on your own. You can go to the health care Marketplace to look at available plans, or if you know of an insurance company you like already, you can go directly through them to sign up. Because of the ACA, insurance companies cannot turn you down because of pre-existing conditions. They will ask, however, your age, if you smoke, and what state you live in, among other things.

Important!

You can only go through the Marketplace during the enrollment period, which is November 1st to December 15th. However, you can enroll outside of this time if you have a life change like marriage, the birth or adoption of a child, or losing your job.

Previously, people who did not sign up for health insurance would be fined. That was changed by the Trump administration.

How do I pay for my health insurance?

If you get your health insurance through your employer, they will deduct your premium from your paycheck. If you get insurance on your own, such as through the Marketplace, you can set up an auto-pay with the insurance company so that your premium will automatically be paid every month. You can also do it the old fashioned way and pay by check or online. Whatever method is best for you, make sure you don’t forget a payment or you could lose your coverage.

Insurance Glossary: Important words to know

When you are researching health insurance, here are some words you will come across:

  • Coinsurance–After you have reached your deductible, this is the percentage that your insurance will automatically pay for costs.
  • Copay–This is a small portion of the fee you pay to your doctor.  The insurance company pays the rest of the remaining fee. A specialist or an emergency room visit is going to have a higher copay than a primary care physician.
  • Deductible–This is the amount you must spend out of pocket before your insurance will pay anything. However, certain services will be covered even if you haven’t met your deductible. Typically the lower the deductible, the higher your monthly premium.
  • Out-of-pocket–These are costs that you pay on your own, whether it be your copay or services that your insurance does not cover. 
  • Out-of-pocket maximum–This is the maximum amount you will pay out of pocket for covered services. After you reach this amount, insurance will pay 100% of covered expenses.
  • Premium–This is the amount you pay to the insurance company every month to be a member of the plan. If you are getting your insurance through your employer, they usually pay a percentage of this cost.

Types of Health insurance plans in the US

Exclusive Provider Organization (EPO)

In this plan, insurance will only cover visits to doctors, specialists, or hospitals that are in-network. You do not need to get a referral from your primary care physician (PCP) to see a specialist.

Health Maintenance Organization (HMO)

This covers visits from doctors who are contracted through the organization and focuses on covering prevention and wellness services. You need a referral to see a specialist.

Point of Service (POS)

Your copay will be less using this plan if you use health care providers that are within the plan. You must get a referral to see a specialist.

Preferred Provider Organization (PPO)

A type of health plan where you pay less if you use providers in the plan’s network. You do not need a referral to see a specialist. You can also see doctors, hospitals, and other medical providers outside of the network without a referral, but for an additional cost.

Medicaid

This is a government-provided insurance program for low-income people, pregnant women, the elderly, and people with disabilities. The program is low-cost or sometimes even free. The qualifications and coverage will vary by state and you can enroll at any time.

Medicare

Another government health insurance plan, this program is specifically for people 65 and older, some younger people with disabilities, and people with end-stage renal disease. There are three types of Medicare: Part A for hospital visits, Part B for general medical care, and Part D for prescription drugs. Part C is a “bundle” insurance that includes all three parts and is called Medicare Advantage.

How can I save for health care costs?

Besides savings in your own bank account for health care costs, you can also sign up for a Flexible or Health Savings Account, or FSA and HSA. These plans are for people who have high deductible health insurance plans. It allows them to deposit money that is not taxed to pay for medical expenses. In a Limited FSA, the expenses go towards vision and dental insurance.

So what is the difference between the two savings accounts? The biggest difference is that you must spend all the money in your FSA within a year (although there is sometimes a 2.5-month grace period). In an HSA, you can roll over the money into the next year. 

Also, there is a limit to how much you can put into these accounts, which is different for both types of accounts. The maximum deposit for individuals is $2,750 for an FSA and $3,500 for an HSA. The limit is higher when the account is for a family.

If your job offers an FSA or HSA, they might contribute to the account.

Share

Related articles