US Health Insurance System

 How Does the US Health System Work?

Healthcare in the United States is organized in a complex bureaucracy. While in the rest of the world healthcare facilities are owned mostly by governments or by private sector businesses, in the US a large share of hospitals and clinics are owned by private non-profit organizations.

Yet, the United States is the country that has the highest healthcare expenditures in the world. While these expenditures are covered in a large share by public payers as by Federal institutions, or State and local governments, they can also be covered by private insurance and individual payments.

At the same time, unlike most developed nations, the US health system does not provide health care to its entire population. As there is no single nationwide system of health insurance, the United States primarily relies on employers who voluntarily provide health insurance coverage to their employees and dependents.

In addition, the government has programs that tend to cover healthcare expenses for the fragile parts of society as the elderly, disabled, and the poor. These programs differ from one another, and all have a specific kind of people that are subjects to.

Getting health insurance in the US is not an easy thing. Someone may think that once you have money everything is easy peasy, but in fact, things are a bit more complicated. One must be very careful and look out to pick the right insurance.

Health Insurance in the United States for non-Citizens

The United States government does not provide health insurance for all its people, and health insurance is not obligatory for those living in the US. It is optional but highly recommended and necessary since health services are very costly, more than in any other country anywhere across the globe.

There are two types of health insurance in the US, private and public. Most people use a combination of both. The US public health insurances are Medicare, Medicaid, and the Children’s Health Insurance Program.

·         Travel insurance for visitors in the USA

·         Health insurance for international students in the USA

·         Health insurance for dependents of international students.

·         Health insurance for J-1 visa holders

·         Health insurance for foreign workers on an H-1B visa

·         Health insurance for dependents on an H-4 visa holders

·         Health insurance for Green Card Holders

·         Health insurance for K1 visa holders

·         Health insurance in the USA for Canadian Expats

The US has the most expensive healthcare in the world. That’s why getting adequate health insurance coverage comes highly recommended.

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Medicare

Medicare is a national health insurance program that dates back to 1966. It provides health insurance for US nationals older than 65 years old, but also for younger people with end-stage renal disease, ALS, and some other disabilities.

Data shows that in 2018, Medicare provided almost 60 million individuals with healthcare in the US, over 51 million of which were older than 65.

The Medicare program is divided into four parts:

·         Part A – which covers hospitals, skilled nursing, and hospice services.

·         Part B – covers outpatient services, including some providers’ services while inpatient at a hospital, outpatient hospital charges

·         Part C – is an alternative called Managed Medicare, which permits patients to select health plans with at least the same service coverage as Part A and B, often the benefits of Part D, and an annual out-of-pocket spend limit which A and B lack. To sign in this part, one must sign in Part A and B first.

·         Part D – covers mostly self-administered prescription drugs.

Medicaid

Medicaid is a federal and state program that helps people with limited income and resources to cover medical costs while covering benefits normally not covered by Medicare, such as nursing home care and personal care services.

It is the largest source of funding for medical and health-related services for people with low income in the United States. Data shows that the US provided health insurance to 71 million people with low income or disabilities, which is 23% of the total US population.

Children’s Health Insurance Program

Formerly known as the State Children’s Health Insurance Program (SCHIP), this is a program that covers health insurance for children of families with a modest income, that is not low enough to qualify for Medicaid.

The Affordable Care Act – Obamacare

The Patient Protection and Affordable Care Act is a federal statute signed into law by President Obama, which made it mandatory for every citizen to have health insurance or be penalized. The Act subsidizes for low-income families, by taxing healthcare providers and high-income families, as it was designed to lower health care costs while providing better health care for Americans.

The Affordable Care Act allowed parents to ad their children up to the age of 26 to their policies, in a bid to have younger healthy people paying premiums. It also allowed poorer people to get treatment for chronic illnesses instead of using the emergency room.

US Private Health Insurance

There are about a thousand private health insurance providers in the US, with each of them offering different plans at different prices, which largely depend on a person’s medical history. However, while there are individual plans, covering only one person, there are also group plans targeting families in particular.

Usually, there are three types of health insurance in the United States:

·         Traditional fee-for-service health insurance plans which plans are usually the most expensive, that those with an income lower than the average income in the US, have difficulties purchasing. However, these are the best plans as they offer you the most flexibility.

·         Health Maintenance Organizations (HMOs) offer a limited choice of healthcare providers, yet it also offers lower co-payments and covers the costs of more preventative care. They are evaluated and accredited by the National Committee for Quality Assurance.

·         Preferred Provider Organizations (PPOs) which just like HMOs offer lower co-payments, but they give you more flexibility when selecting a provider, as they give you a list of providers among which you can choose.

How to Choose a Good US Health Insurance Plan?

When looking up a good health insurance plan make sure you ask questions like:

·         Does that plan grant you the right to go to any doctor, hospital, clinic or pharmacy you choose?

·         Are specialists such as eye doctors and dentists covered?

·         Does the plan cover special conditions or treatments such as pregnancy, psychiatric care, and physical therapy?

·         Does the plan cover home care or nursing home care and medications a physician might prescribe?

·         What are the deductibles? Are there any co-payments?

·         What is the most you will have to pay out of your own pocket to cover expenses?

Make sure you also understand how a dispute about a bill or service is handled by your provider, as in some plans, you may be required to have a third party decide how to settle the problem. We recommend the GeoBlue Xplorer plan for foreigners in the United States

Health Insurance Requirements for Foreign Visitors in the US

Though the United States Authorities have not made health insurance mandatory for short-term travelers to the country, as B-1/B-2 visa holders, it is highly recommended for every traveler to get insurance before their trip to the country.

The main reason why you should get insurance is that healthcare in the US is extremely expensive and even a check-up for a simple headache will cost you hundreds of dollars, while a broken limb will cost you thousands.

Health incidents are never foreseen, therefore it is best to be prepared for it and get insurance, so in case of need you save yourself money.

Health Insurance Options for Legal Immigrants

Immigrants that are lawfully present in the United States are eligible to get private health insurance in the US. In addition, lawful immigrants may also be eligible for lower costs on monthly premiums and lower out-of-pocket costs based on their income, as follows:

·         Those with an annual income of 400% of the federal poverty level or below may be eligible for premium tax credits and other savings on Marketplace insurance.

·         Whereas those with annual household income below 100% federal poverty level that is not otherwise eligible for Medicaid are eligible for premium tax credits and other savings on Marketplace insurance, given that they meet all other eligibility requirements.

Most of the time, “qualified non-citizens” are eligible for coverage through Medicaid and Children’s Health Insurance Program (CHIP), given that they meet the income and residency rules of the state where they are based.

“Qualified non-citizens” are considered the following:

·         Lawful permanent residents

·         Asylees, refugees, battered non-citizens & spouses, children, or parents, victims of trafficking and or their spouse, child, sibling, or parent, or individuals with a pending application for a victim of trafficking visa

·         Cuban/Haitian entrants,

·         Those paroled into the US for at least one year

·         Conditional entrant granted before 1980

·         Those granted withholding of deportation and members of a federally recognized Indian Tribe or American Indian born in Canada.

However, most of them will need to wait for 5 years in the US in order to get Medicaid and CHIP coverage in the US, after they get qualified. Refugees and asylees are exempt from the waiting period.

In addition, states have the option to abolish the 5-year waiting period for children and pregnant women so they can be covered by Medicare and CHIP.

You can get a free US health insurance quote here. While you are free to choose the plan that suits you best, we recommend the GeoBlue Xplorer.

Health Insurance Options for Illegal Immigrants

Illegal Immigrants in the US can get health coverage only from private providers, as the US government-funded health insurance does not cover them.

Community centers can provide medical help to undocumented immigrants in the US, which is termed Safety Net Providers if the healthcare seeker can participate in fee-for-service medical assistance.

 

Understanding Your Insurance Policy

Understanding Your Insurance Policy  

An insurance policy is a legal contract between the insurance company (the insurer) and the person(s), business, or entity being insured (the insured). Reading your policy helps you verify that the policy meets your needs and that you understand your and the insurance company’s responsibilities if a loss occurs. Many insureds purchase a policy without understanding what is covered, the exclusions that take away coverage, and the conditions that must be met in order for coverage to apply when a loss occurs. The SCDOI would like to remind consumers that reading and understanding your entire policy can help you avoid problems and disagreements with your insurance company in the event of a loss.

The Basics of an Insurance Contract

There are four basic parts to an insurance contract:

o    Declaration Page

o    Insuring Agreement

o    Exclusions

o    Conditions

It is important to understand that multi-peril policies may have specific exclusions and conditions for each type of coverage, such as collision coverage, medical payment coverage, liability coverage, and so on. You will need to make sure that you read the language for the specific coverage that applies to your loss.

The Declaration Page

This page is usually the first part of an insurance policy. It identifies who is the insured, what risks or property are covered, the policy limits, and the policy period (i.e. the time the policy is in force).

For example, the Declarations Page of an automobile policy will include the description of the vehicle covered (e.g. make/model, VIN number), the name of the person covered, the premium amount, and the deductible (the amount you will have to pay for a claim before an insurer pays its portion of a covered claim).

Similarly, the Declarations Page of a life insurance policy will include the name of the person insured and the face amount of the life insurance policy (e.g. $25,000, $50,000, etc.).

The Insuring Agreement

This is a summary of the major promises of the insurance company and states what is covered. In the Insuring Agreement, the insurer agrees to do certain things such as paying losses for covered perils, providing certain services, or agreeing to defend the insured in a liability lawsuit. There are two basic forms of an insuring agreement:

o    Named–perils coverage, under which only those perils specifically listed in the policy are covered. If the peril is not listed, it is not covered.

o    All–risk coverage, under which all losses are covered except those losses specifically excluded. If the loss is not excluded, then it is covered. Life insurance policies are typically all-risk policies.

The Exclusions

Exclusions take coverage away from the Insuring Agreement. The three major types of Exclusions are:

o    Excluded perils or causes of loss

o    Excluded losses

o    Excluded property

Typical examples of excluded perils under a homeowners policy are floods, earthquakes, and nuclear radiation. A typical example of an excluded loss under an automobile policy is damage due to wear and tear. Examples of excluded property under a homeowners policy are personal property such as an automobile, a pet, or an airplane.

The Conditions 

Conditions are provisions inserted in the policy that qualify or place limitations on the insurer’s promise to pay or perform. If the policy conditions are not met, the insurer can deny the claim. Common conditions in a policy include the requirement to file a proof of loss with the company, to protect property after a loss, and to cooperate during the company’s investigation or defense of a liability lawsuit.

Definitions 

Most policies have a Definitions section, which defines specific terms used in the policy. It may be a stand-alone section or part of another section. In order to understand the terms used in the policy, it is important to read this section.

Endorsements and Riders

An insurer may change the language or coverage of a policy at the time of the policy renewal. Endorsements and Riders are written provisions that add to, delete, or modify the provisions in the original insurance contract. In most states, the insurer is required to send you a copy of the changes to your policy. It is important that you read all Endorsements or Riders so you understand how your policy has changed and if the policy is still adequate to meet your needs.

Want to Review Your Policy? 

To obtain a copy of your insurance policy, please contact your insurance agent or company.