Personal experience: we deal with medical insurance in the USA
'02.04.2021'
After moving to the United States, one of the most difficult topics for me to understand was medicine. A lot of effort and nerves was spent before I began to understand the question well. Moreover, I even had to fill a few bumps. It's best to start understanding local medicine from scratch - from insurance.
In the United States, there is no state medicine, all of it is private and is built according to the principle: Sick – Insurance – Doctor (medical service). Some categories of citizens do not need to buy insurance themselves, they will be given it by the state, but all the same, the principle of relationship will be the same.
"Is it possible to do without insurance?" - you ask. Recently, yes, but this is a risk of getting into big bills from clinics. If you are ready for this, this is only your choice.
In our family, health insurance is almost entirely covered by the employer, but we also contribute a monthly amount to the insurance. Once a year, our company offers a choice of several plans from one insurance company. To decide on a package of services, it is not enough just to choose according to the principle “more expensive - cheaper”.
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Already at this stage, you need to understand a certain number of terms, weigh certain risks, otherwise later, when used, you may have to wait for disappointment, which will primarily concern the financial component. I suggest you to deal with all the terms and nuances.
Here is the first thing you need to understand, remember and always keep in mind.
There is the concept of IN-NETWORK (“on the network”) and OUT-OF-NETWORK (“off the network”). This applies to doctors, clinics, laboratories. They can be part of the insurance network, that is, have a cooperation agreement with prescribed tariffs and working conditions - IN-NETWORK (“in the network”). Or not to have such an agreement - OUT-OF-NETWORK (“offline”). In the second case, the prices and conditions of service are not regulated by the insurance company, which is more risky for them and, accordingly, at any time the insurance company can receive bills from medical institutions for any amount. This, of course, will not please anyone.
So always check before making an appointment with your doctor to see if he is part of your insurance network. Now you need these concepts in order to estimate what conditions your tariff plan has for working online and offline.
Plans are generally divided into High DEDUCTIBLE and Low DEDUCTIBLE.
DEDUCTIBLE is the amount you pay out of your pocket. When it is reached, the insurance company begins to pay for everything itself.
What does it mean? For example, in the network, the sum of deductable will be zero, i.e. the insurance will fully cover your visits, and already outside the network you have to pay $ 2000 per person and 4000 for a family out of your pocket. And only after reaching this amount, the insurance will start paying bills for you. High DEDUCTIBLE has completely different amounts: you pay much more both online and offline.
The next very important concept for understanding the principles of insurance is Copayment.
Literally, “co-payment” is the amount that you always pay yourself under certain conditions.
For Low DEDUCTIBLE, a visit to an online therapist will always cost you $ 20, the rest of the bill will be paid by the insurance company. For example, the bill for a visit is $ 300: you pay $ 20, and the insurance bill $ 280. Moreover, often a copy is paid immediately on the day of the visit, but not always. For the "offline" category, as we can see from the table (second column), the conditions are worse: you will pay 60% of the cost after the deactible occurs, and before it, respectively, the entire bill.
For High DEDUCTIBLE, the amount of the copy will be higher both "online" and "offline". Copies will also be available when you go to the ambulance if you need to stay in the hospital for some hours. But there is no credit for all types of preventive care: annual examinations, vaccinations, checks, pregnancy, emergency cases (AMBULANCE) - this kind of service.
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Accordingly, choosing a plan with High DEDUCTIBLE, you get a lower MONTHLY cost of insurance, but much more expensive services when you apply. Who is it suitable for? Definitely those who rarely seek help, have no chronic diseases, and most likely people are childless.
Whereas Low DEDUCTIBLE is a plan when you pay a large monthly amount for insurance, but you feel more confident when you go to the doctors knowing that you will be covered almost 100% everywhere, with the exception of pennies. This is definitely more convenient for those who often go to doctors, or those who are not ready to take risks.
What to choose is up to you. But definitely remember: when you go to a clinic from the “online” category, you pay less than in an “offline” institution.
The original column is published in the author's blog. jerseypine.blogspot.com.
