How Health Insurance Works in the United States

Medical insurance in the USA can be a bit complex. As a result, many of us ask ourselves different questions: How does health insurance work in the United States? What health insurance should I choose? Can I access a health policy without papers? All these questions and many others you will find in the following words.

How Health Insurance Works in the United States

Health care in the United States can be incredibly expensive . A visit to the doctor can cost hundreds of dollars and an average three-day hospital stay can run into the tens of thousands of dollars, depending on the type of care provided.

In fact, according to data provided by The National Health Expenditure Accounts in its 2019 study, people in the United States spent about 17.7% of their GDP on medical expenses. This equates to $ 3.8 trillion or an average of $ 11,582 per person. Most people in the US cannot cover such large sums of money every time they get sick .

Now, from this premise the following question arises .

What is health insurance?

The health insurance or health insurance emerges as a solution to high health care costs in the United States. Through this economic system, people can share the risks associated with health and lower prices. Health insurance can be private, social, or financed by the government through a public welfare program.

This concept arises from the insurance in cases of accidents in 1850, which rapidly expanded to the health area in 1890. And it was not until 1911 that the public benefit was established among the country's employers , encouraged by the policies progressive government.

How does health insurance work?

Simply put, health insurance works by paying a premium up front to the company, allowing you to share the "risk" with many other people who make similar payments . Since most people are healthy most of the time, the premiums paid can be used to cover a smaller number of people enrolled who are sick or injured.

In this sense, if you get sick at some point, the insurance can help you cover the costs related to your illness . However, these concepts can be a bit more complicated in practice for the following reasons:

• Many people are interested in medicine as a form of business
• Patients usually do not know what they need or what treatment they are receiving
• Healthcare providers usually get money from insurance
• The rules established by the insurers determine the distribution of resources

As a consequence, it is difficult for normal market rules to apply to health insurance . However, for their part, insurance companies also have some reasons for changing the rules of the game.

Why is the United States not universalizing health?

First of all, we must consider a very important principle. Health is considered globally as a human right. In this sense, if a decision is made or a health law is applied, they will not be able to reverse it easily .

For example, suppose Congress and Senate approve free health for all people. As a result, many insurance companies, clinics, hospitals, and other healthcare workers will see their earnings decline and many companies could potentially go bankrupt . This creates a knock-on effect that could have devastating effects on the national and global economy.

Continuing with the same example, suppose they take action in time and decide to take a step back from the previous legislation. The truth is that it could not be applied because international law does not allow the regression of rights. Once a state legislates on a human right, it is internationally illegal to remove it .

How does supply and demand affect the healthcare market?

Now, health companies measure the different risks that can happen in people's lives. Otherwise, the system could be thrown out of balance . For example, what happens if a very large number of people demand health services at the same time in cases of pandemic, for example?

The reality is that the insurance industry would immediately go out of business because they don't have enough money to cover all the payments . After all, the system relies on a small, rotating percentage being served.

Also, it is very difficult to monitor the quality of service. According to government legislation, the medical profession is in charge of monitoring itself through accreditations, licenses, and other mechanisms . However, neither the patient nor the insurance can determine the quality of the service because they do not know exactly the quality of the system.

In this sense, there is no alternative but to trust that the amounts effectively represent the service that is being provided .

Why is health insurance so expensive in America?

Health is a factor that cannot be calculated mathematically or at least not easily. Events such as the COVID-19 pandemic have occurred, in which the health system became unbalanced and not all people could be served. Increased demand raises prices and many people go into debt .

Since insurance does not know for sure how much medical expenses cost for the specific person, it is very difficult to determine an exact price . For that reason, they have no other way out than to raise prices. For that reason, health insurance is very expensive.

What is a fact is that the life expectancy of people is constantly increasing and one of every six dollars spent in the United States is directed to the health market . And both numbers keep going up.

As you can see, insurance companies study these risks in great depth with the intention of raising enough money to cover the medical costs of enrollees and make a profit. For this reason, there are some factors that insurance takes into account when setting prices.

Factors Affecting Premium Prices

1. State and federal laws . US law dictates what health insurance should cover and how much insurance companies can charge.
2. The type of insurance . Insurance that is part of group plans - such as those offered by employers - tend to be much cheaper than individual or private insurance.
3. Income of the holder . Low-income workers tend to pay more through employers, but pay less through state or federal markets as a result of subsidies
4. The size of the employer . Insurance companies are cheaper when companies are larger. This is because they can spread the risks even more and spend less as a result.
5. The state and county in which you live . Premiums tend to be cheaper in urban areas than in rural areas. Also, some counties may have only one plan, while others tend to have more competition - lowering prices as a consequence.
6. The type of plan you choose . PPOs and Platinum plans tend to cost more in the federal health insurance marketplace.
7. The risks of health insurance

Health insurance risks

• Age
• Build
• Physical condition of the person
• Tobacco use
• Personal medical history
• Family medical history
• Occupation
• Place of residence
• Sex
• Aviation activities
• Hobbies or other activities

All insurance companies have specific guidelines that they rely on when deciding the cost of premiums . Here is a list of some of the aspects that are taken into account to establish the amount of your insurance.

Age

Age is one of the most important factors when measuring the probability of getting sick . At the time of applying, it is likely that they will ask you your age group and other risk factors that are compared with the norms of each institution.

All insurance companies have a minimum and maximum age range in which you may be eligible to apply for coverage . Depending on the company, the maximum ages can be as low as 60 years and in others as high as 80 years.

Regardless of other factors, if you apply with a company and are over the maximum age, you may not be insurable . On the other hand, there is no minimum age. However, minors must have an adult holder, unless they are emancipated or have special conditions.

Build

Your build - the relationship between your height and weight - is one of the basic aspects to determine your probability of suffering from a disease . These usually vary according to the insurance company, but the table below can serve as a guide.

Example of a table of health insurance builds for people between 20 and 69 years old
Size	Average weight (Standard)	Average weight limit zone (up to 150% of standard weight)	Special category for overweight (between 150% and 350% of the standard weight)	Rejected person if he exceeds this weight
4’8»	76 – 147	148 – 160	161 – 223	223
4’9»	79 – 152	153 – 166	167 – 231	231
4’10»	82 – 158	159 – 172	173 – 239	239
4’11»	84 – 163	164 – 178	179 – 247	247
5’0»	87 – 169	170 – 184	185 – 256	256
5’1»	90 – 174	175 – 190	191 – 264	264
5’2»	93 – 180	181 – 197	198 – 273	273
5’3»	96 – 186	187 – 203	204 – 282	282
5’4»	99 – 192	193 – 210	211 – 291	291
5’5»	102 – 198	199 – 216	217 – 300	300
5’6»	106 – 204	205 – 223	224 – 310	310
5’7»	109 – 211	212 – 230	231 – 319	319
5’8»	112 – 217	218 – 237	238 – 329	329
5’9»	115 – 223	224 – 244	245 – 338	338
5’10»	119 – 230	231 – 251	252 – 348	348
5’11»	122 – 236	237 – 258	259 – 358	358
6’0′	125 – 243	244 – 265	266 – 369	369
6’1′	129 – 250	251 – 273	274 – 379	379
6’2′	133 – 257	258 – 280	281 – 389	389
6’3′	136 – 264	265 – 288	289 – 400	400
6’4′	140 – 271	272 – 296	297 – 411	411
6’5′	143 – 278	279 – 304	305 – 422	422
6’6′	147 – 286	287 – 311	312 – 433	433
6’7′	151 – 293	294 – 320	321 – 444	444
6’8′	155 – 300	301 – 328	329 – 455	455
6’9′	159 – 308	309 – 336	337 – 467	467
Body Mass Index	17-33	33.1 – 36	36.1 – 50	+50

If you are within an average age and weight, then your build will have a neutral factor . If not, this may be a cause for you to move to another sub-standard class of risk.

Physical condition

Insurance companies will want to know if you have a physical or mental disability that could be risky to your health . In the application, you will be able to see some questions related to specific health issues and, if necessary, the institutions will be able to request a history and a medical examination.

The first purpose of the medical exam is to detect organs that are not working properly . A urine or blood test can also help determine this.

In some cases, insurance companies do not offer coverage if you have surgery in the days close to signing the contract , if you have specific medical conditions or have not yet recovered from an illness.

Read on: Financial Aid During Family Medical Leave

Tobacco use

It is no secret to anyone that smoking is harmful to health. If you smoke cigarettes, your classification will be found as Tobacco risk class , which will make you pay more money.

Now, depending on the company, tobacco use in other ways can be viewed differently . For example, pipe smokers, tobacco chewers, e-cigarette users, nicotine gum chewers, and marijuana smokers might be in a different risk classification.

Some companies may classify the insured as risk-free for tobacco use, while others may classify them as a consumer . If you apply to several insurance companies, you will be able to see the differences in each one of them.

Personal medical history

Insurance companies will also want to know if you use drugs or consume alcohol . The companies will take a look at your past to see if there is any history that shows the consumption of these, since they could have caused irreparable damage to your body.

Any current use of strong drugs could cause the automatic denial of the contract . In the case of marijuana, this can vary by company. And only worry about alcohol consumption is more than moderate. After all, if you drink a lot, there is a substantial risk of mortality.

Another aspect that they will see is your medical history . At the end of the day, this is one of the crucial aspects that will determine the price of your premium. If your history shows the possibility of suffering from a pre-existing disease or condition, then your premium will be more expensive. But if you do not have diseases and you live a relatively healthy disease, the cost of the premium will decrease.

Personal history can also reveal potentially worrisome work or life environments . For example, if an applicant has just finished a dangerous job, chances are that their health will be affected.

Finally, insurance companies will want to know if you already have an insurance policy or have been denied one in the past . This affects the amount of coverage that can be approved for you. If you have been rejected in the past, it is very likely that the reason is still valid.

Family medical history

Since certain conditions are inherited, family history plays an important role in health insurance . When you apply for one, they will ask you about the age and health status of your parents and siblings. Some questions may be if any of them have already suffered from any disease, the age at which they died (if any) and in what condition they are.

When determining the risk class of the applicant, a good family history will be positive , while a poor family history can subtract some points in the general evaluation.

Occupation

There are jobs that can be considered dangerous, reducing the health or life expectancy of the person . These are viewed this way because there is a greater chance of an accident occurring. Examples are construction workers, those who work in an unhealthy environment, or miners.

All insurance companies have an occupational manual , which shows the tasks that can have an adverse effect on health. If you work in one of these occupations, you will likely be asked for a higher premium.

If you bought a policy and paid more for your work, but later switched to a less dangerous job, you could ask the insurance policy for a reconsideration . Depending on the circumstances, your risk class may be changed and your premiums lowered.

Place of residence

Disease and death rates vary widely around the world . That is why they will ask you where you live. They will also want to know if you have recently traveled or lived in another country. Climate, living standards, sanitary conditions, medical care, political stability and other factors could put your health and life at risk.

In addition, it is important to take into account that the prices of health care are different in different regions of the country . For example, going to a hospital in New York is not the same as going to a hospital in Texas. Prices change and so do insurance policy premiums.

Sex

In statistical terms, women live longer than men and get sick less . According to the Centers for Disease Control and Prevention (CDC), the life expectancy of women is 4.9 years longer than that of men.

Although there are many reasons to determine this analysis, we can mention among the most outstanding that women are more conscious of their own health , are willing to go to the doctor when necessary and their behaviors are less risky than those of men.

For this reason, when women do not apply for maternity coverage, they tend to pay less for policies than men - except in the state of Montana, where there is a unisex insurance law.

Hobbies, hobbies and other activities

As with occupations, some activities are considered dangerous . Most of these are associated with racing, skydiving, scuba diving, and mountain climbing.

If you apply for health insurance and you are not one of the holiest, you may have to pay an additional amount for your premium . This is an additional fee that health insurance uses as a cushion to insure you. Although this amount varies by insurer, it is typically between $ 3 and $ 10 for every $ 1,000 of coverage.

NOTE: Not all insurance companies take these factors into account and not all take it in the same way. However, the factors mentioned above can serve as a guide to understand how the system works.

There are many forms and types of health plans in the United States and many different rules for medical care. However, there are three important questions to ask when making a decision about the health insurance that is best for you .

Where can I get medical attention?

One way that health insurance plans can control their costs is by influencing access to providers . Normally, a large number of specializations are included, among which we find hospitals, pharmacies, laboratories and other entities.

Many insurance companies contract with a specific network of providers who agree to provide their services to those enrolled in the plan at a more favorable price.

If a provider is not in the plan's network, the insurance company may not pay for the services provided, or it may pay a portion of the total , equal to what it would pay for care in its network.

This means that insurance subscribers who go out of network to get medical care may have to pay a higher amount of the cost. This is an essential aspect to understand, especially if you are not originally from the area.

If you have an insurance plan through a family member, for example, and the plan's network is in your hometown, you may not have access to health care in another area, or you may have to pay a much higher price for the cares .

What does medical insurance cover in the USA?

One of the changes that health care reform has made in the United States under the ACA is to introduce a standardization of health plan benefits . Before this standardization, the benefits offered varied dramatically depending on the plan.

For example, some plans covered prescriptions, while others did not. Now, the law in the United States requires that a specific number of “essential health benefits be offered , which must include the following:

• Emergency services
• Hospitalization
• Laboratory tests
• Maternity and newborn care
• Mental health and substance abuse treatment
• Out-of-hospital care
• Prescription drugs
• Preventive services
• Rehabilitation services

Emergency services

Emergency services are for all types of health problems that require emergency care , including any of the following:

• Heart attacks
• Strokes
• Motor vehicle crashes
• Psychiatric emergencies
• Other life-threatening conditions

Emergency departments are open and available 24 hours a day, every day of the year . This unit has special teams and qualified doctors, assistants and nurses to respond to all types of emergencies, coming from people of any age.

Emergency physicians are federally mandated to provide care to all patients, even regardless of their ability to pay. For that reason, no doctor will be able to turn you away based on your health insurance status. However, if you do not have health insurance, you could have to pay a large debt to the hospital.

Hospitalization

When an emergency occurs or there is a serious health problem, doctors recommend hospitalization. Staying in the hospital can be very expensive, even from day one, and it can happen at any time .

Even with health coverage, out-of-pocket expenses like deductible, rehab, and transportation can add up to a pretty high amount of money. Thanks to the concept of hospitalization in health insurance, policyholders can receive similar help to cover expenses .

Laboratory tests

When they tell us laboratory tests, the first thing we think about is a blood test. However, it is most likely that doctors require much more modern tests with information that may be relevant to find diseases . These specialized tests can be inexpensive in many cases, but can be quite expensive in others.

In this sense, health insurance covers laboratory tests carried out in the hospital . At the end of the day, it is a necessary step to cure the disease that the patient and the insured have.

Maternity and newborn care

These services are provided before, during and after a child is born and is considered an essential benefit , according to the Healthcare.gov Marketplace . This means that all plans must have it, not only within the government market, but also outside of it.

This coverage makes it easier to get checkups and medical exams to help the mother and baby during the pregnancy period . Some mothers find it difficult to work in and of itself, so it can be even harder to pay for high medical costs or lead to medical debt that affects credit .

Depending on the coverage, your health insurance may be transferable to the baby for a limited time . Providing a limited time for parents to secure the child with some benefits.

Mental health and substance abuse treatment

Health insurance often has essential benefits that cover mental health as well as substance abuse treatment. For example, there may be behavioral health treatment - such as psychotherapy or counseling; Inpatient services for mental health or substance use disorder treatment, such as alcohol or drugs.

However, you should take into account that these benefits can vary widely depending on the state in which you live, the health insurance and the plan you choose . And although it is not something that happens every day, it is best to take a look at it before signing any document.

Preventive Services (Outpatient Care)

Also known as outpatient care, these are medical services that do not require a stay in hospital facilities . This type of service is usually less expensive because the treatments are less invasive and do not require ongoing patient care. In this sense, it uses fewer resources.

Among the different services related to outpatient care, we can find:

• Services routine, such as medical checkups
• Minor surgeries , in which hospitalization is not required
• Treatments
• Rehabilitation
• Mental health services
• Primary care
• Specialty care
• Others

Preventive services are aimed at helping people stay healthy and detect health problems early , when there are better chances of recovery. For this reason, doctors recommend that people have regular medical check-ups, even if the person is not feeling unwell.

All people have different types of services that are offered under this concept. Here are some of the services that are included :

Exclusive preventive services for children

• Autism assessment
• Behavioral assessments
• Immunization shots for children
• Congenital hypothyroidism screenings for newborns
• Depression screening
• Developmental examination
• Examination of dyslipidemia
• Fluoride chemoprevention supplements for children who do not have fluoride in their water source
• Hearing screening for newborns ; and for children once between 11 and 14 years old, once between 15 and 17 years old, and once between 18 and 21 years old
• Height, weight, and body mass index measurements
• Hematocrit or hemoglobin test
• Iron supplements for children 6 to 12 months at risk of anemia
• Lead screening for children at risk of exposure
• Vision test

Specific preventive services for women

• Examination for anemia
• BRCA Counseling for Women at Higher Risk
• Breast cancer mammogram and chemoprevention counseling
• Counseling on breastfeeding
• Cervical Cancer Screening
• Contraception
• Detection and counseling on domestic and interpersonal violence
• Certain items and services for pregnant women
• Screening for gestational diabetes
• Osteoporosis examination
• Rh incompatibility test
• Preventive services for adults
• Examination of abdominal aortic aneurysms ("AAA")
• Examination and counseling on alcohol use
• Using aspirin to prevent cardiovascular disease
• Blood pressure test
• Cholesterol screening
• Colorectal Cancer Screening for Adults 50-75 Years
• Depression screening
• Dietary advice
• HIV test
• Immunization shots
• Obesity screening and counseling
• Counseling for the prevention of sexually transmitted infections
• Syphilis test
• Examination of tobacco use
• Screening for type 2 diabetes

Prescription drugs

Coverage of prescription medicines helps you pay for prescription drugs you need to treat the disease . Even if you don't need it right now, this is an important factor to consider. After all, this is the most common method doctors use to treat illnesses that do not require emergency services.

The best part is that these insurance services work directly with the most popular pharmacies on the market , such as Walmart or CVS . And you don't even have to go to the store in many cases. You can simply request it through the application or by phone.

Rehabilitation services

Most health providers have some measure time for addiction treatment coverage . And because addiction is viewed as a medical condition, insurance provides resources for recovery.

However, it is important to note that each insurer takes a different position when it comes to rehab and detox . It is important that you understand what your benefits are before purchasing any program. Some companies offer better coverage for the facilities that are in their network and you do not want to buy a program that you cannot afford.

How much does health insurance cost?

Understanding what insurance coverage covers is quite complicated. Typically, we talk about paying a premium to join a plan . This is an upfront payment that must be completely transparent. That is, they will tell you exactly how much you have to pay.

Unfortunately, in many plans, this is not the only cost associated with the care you will receive . There are also other costs when you access health care. This cost translates into deductibles , co-insurances and co-payments .

As a rule of thumb, the more money you pay for the premium, the less you will have to pay when accessing health care . The less money you pay for the premium, the more you will have to pay in order to be cared for.

Is it better to make a big payment now or make a big payment later?

The truth is that there is no correct answer . Ultimately, you will pay for the treatment you receive. Normally, we consider it best to pay as much premium as possible to minimize costs incurred at the time of service - or at least as much as possible.

The reason is that we don't want any barriers to get in the way of health care , such as co-payment at the time of service. This will allow you to access medical care at any time that is necessary.

What are the types of health insurance?

• Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Exclusive Provider Organizations (EPOs)
• Point of Service Plan (POS)
• Fee-For-Service (FFS)

Health Maintenance Organizations (HMOs)

HMOs or Health Maintenance Organizations give you a local network of doctors, hospitals and other health services to visit . These types of health insurance plans also require that you choose a primary care provider (PCP) from the network. This PCP will be the central site where health care will be provided.

Thanks to the Primary Care Providers (PCP), they will be able to get to know you and help you coordinate all your care . In addition, they will provide you with all the references and specialists. The costs for an HMO health plan - copays and coinsurances - are typically lower than other types of health plans, as long as you use network providers.

Preferred Provider Organizations (PPOs)

PPOs or Preferred Provider Organizations usually offer a very large network of participating providers so that the user has a wider range of options when accessing doctors, hospitals and other services or health professionals. In addition, this system allows access to providers that are outside the service network, but will have to pay a higher rate.

With this type of plan, it is not necessary to choose a Primary Care Provider (PCP), nor will you have to obtain a medical referral to be able to see a specialist doctor

Exclusive Provider Organizations (EPOs)

EPOs or Exclusive Provider Organizations offer users a network of participating providers from which to choose . Most EPO plans do not include coverage for out-of-network care, except for emergencies. In other words, if a provider is visited outside the plan, the user will have to pay for the entire service on their own.

Depending on the plan, the choice of a Primary Care Provider or Primary Care Provider (PCP) may or may not be required . If you want to see a network specialist, you will not need to get a referral from your PCP.

Point of Service Plan (POS)

The Point of Service Plan combines the features of the HMO and PPO plans . The provider network is typically smaller than PPO plans, but the costs are also often lower - just like the HMO.

POS plans require the choice of a primary care provider (PCP) from the network of doctors and other primary care professionals . The PCP will be the base of the care, so the care that will be required must be coordinated very well.

In case a specialist is required, a medical referral will be needed. However, just like the PPO, you will be able to see a specialist either on or off the network. If the doctor is not in the network, the cost sharing will be higher for the user and they will have to be responsible for entering the claims on their own.

Planes Fee-For-Service

Fee-for-service plans are a payment system in which the doctor or health service provider receives a payment for each service provided , which -in essence- rewards medical providers for the volume of services provided, regardless of the result.

Through this system, insurance pays for most of the service and allows them to have a wider network of doctors and hospitals . In addition, you can access two separate policies:

• Basic coverage - Helps pay for regular health care, like doctor visits, hospitalization, and major surgeries
• Major Medical - Helps pay all costs incurred as a result of a chronic illness or serious injury.

Despite this, health insurance costs have seen an exponential increase over the last few decades, so premiums have risen to a point where employers and employees alike prefer other models . To deal with this, insurers created the concept of Managed Care.

Comparison of the types of health plans

Comparison of the types of health plans
Plan type	Are you covered outside the service network?	Do the procedures and specialists require a referral?	Summary
HMO: Health Maintenance Organization	No, except in cases of medical emergency.	Yes, normally.	Lower out-of-pocket costs and a primary doctor coordinates your care. There is less freedom of choice of providers.
PPO: Preferred Provider Organization	Yes, but it is more expensive.	No	More vendor options and no referrals required. Higher out-of-pocket costs.
EPO: Exclusive Provider Organization	No, except in cases of medical emergency.	No	Lower amounts out-of-pocket and no referrals needed. Less freedom of choice of providers.
POS: Point of Service Plan	Yes, but it is less expensive in the service network.	Yes	More provider options and a primary doctor who coordinates your care. Requires references.

Health insurance levels

• Catastrophic
• Bronze
• Silver
• Gold
• Platinum

In health insurance marketplaces , both state and federal, there are typically 5 different categories of medical health plans . These are the different levels that will allow you accesses with greater or lesser benefit.

Catastrophic health insurance

Catastrophic health plans are usually protective measures for extreme cases in which a very low monthly premium is paid, but which require very high deductible payments . This option is normally aimed at people who want to have coverage only for the most catastrophic scenarios, since it does not cover the payment of routine consultations or exams.

Bronze health insurance

This is health insurance that has a fairly low monthly premium amount, but at the same time you will have to cover most of the cost (40%) through deductibles. Insurance tends to direct this level of medical service to people who use it little, but who want to protect themselves in situations that represent very high costs.

Silver health insurance

Although the cost of silver premiums are moderate, the cost that you will have to pay for deductibles is also reduced (30%). And while 10% sounds small, when it comes to an emergency situation where a large amount of money has to be paid, it can save thousands of dollars.

Gold health insurance

Gold health plans tend to have slightly higher premiums, but the amount to pay for deductibles and other expenses is lower (20%). In this sense, this option is usually a little more convenient for people who prefer to pay a little more in advance and not so much when receiving a complicated health news.

Platinum health insurance

The plan with the most expensive premium is Platinum health insurance, but it pays the most when you get medical care (90%). This may be a good option for people who need more medical assistance and who prefer to pay a higher premium in order to cover most of the costs.

What are the health insurance options?

• Private insurance
• Employer Sponsored Insurance
• COBRA coverage
• Association Health Plan
• Federal Employee Benefit Plan
• Individual and family plans
• Public insurance
• Medicare
• Medicare Advantage
• Part D of Medicare
• Medicaid
• CHIP
• Military health system
• Indigenous health service
• Supplemental coverage
• Medigap
• Hospital indemnity insurance
• Dental insurance
• Vision insurance
• Specific disease insurance

Private Medical Insurance in USA

Private health insurance tends to be the most popular option . Thanks to the marketplace and the efforts made by the federal government to universalize healthcare in the country, they have seen a progressive increase in the number of memberships.

This does not mean that all people have the best possible access, but little by little it is being achieved. Next, we show you the various private medical insurances that exist in the USA .

Employer Sponsored Insurance

Employer-sponsored insurance is an insurance policy selected and paid for by the employer that is offered to employees and their dependents . These are also called group plans. Typically, employers share the cost of their premiums with the employee equally. That is, both parties pay half of the benefit.

Among the advantages of employer-sponsored plans , we can get:

• The employer shares the cost of the premium with the employee
• Employer does all the work of choosing plan options
• Employer premium contributions are not subject to federal tax and employee contributions can be made through pre-tax payment , reducing taxable income.

Individual and family insurance policies

Individual and family policies , also called personal insurance plans, are health insurance that you can buy for yourself or your family . If you wish, you can work directly with an insurance agent who will help you see the different plans and costs.

You may be eligible for a government subsidy if you purchase an individual plan that complies with the Affordable Care Act (ACA) . This will help you save money on your health insurance. You could be eligible for a subsidy if your employer doesn't offer health coverage and your household doesn't earn more than 400% of the federal poverty level.

The advantages of having an individual or family insurance plan are:

• You will have the ability to choose an insurance company, plan and options that meet your specific needs .
• You can renew or change your insurance policy, options and company - as long as it is the enrollment period .
• Your plan is not tied to your job, so you can change jobs without losing your coverage .
• You can choose a plan that includes the doctors and hospitals you trust
• You may be eligible for a grant from the federal government to help pay for it - as long as you meet the requirements.

Health insurance by state

• The best health insurances in California
• Cheapest Health Insurance in Texas
• The best health insurance in New York
• The best health insurance in Florida
• The best health insurance in New Jersey
• Massachusetts health insurance
• Minnesota Health Insurance: All Your Options

Association Health Plan (AHP)

Association Health Plan plans are a type of group health insurance for employers that allow small companies and freelancers to access health insurance savings through larger group health coverage.

This plan has been active for decades but more recent regulations have made it easier for businesses to join and sponsor an AHP based on a shared profession, line of business, or geographic region. Thanks to large groups of health insurance, approximately 100 million people have health coverage in the United States.

Federal Employees Health Benefit Plan (FEHBP)

Federal employees and American Indian organizations are eligible for FEHBP insurance , unless the specific position is excluded by law or regulation. Through this system, government employees can choose from consumer plans, high deductible plans, PPO, HMO, FFS, and low premium savings or reimbursable health accounts.

COBRA coverage

COBRA stands for Consolidated Omnibus Budget Reconciliation Act. This law allows workers and their families to obtain the right to keep their employer's insurance plan after losing a job or significantly changing the policy conditions.

However, when you choose to continue your COBRA insurance , you must pay the full cost of the premium . In this sense, the amounts to be paid will be higher because the employer will not have the obligation - or the interest - to cover this amount.

Public Health Insurance in USA

In the United States, there are several initiatives that seek to universalize access to health for its inhabitants. Some perspectives are more conservative, working only with Americans or residents, while others seek to involve everyone who lives in the country. Regardless of the point of view, the truth is that public insurance in the USA is the following .

Medicare

Medicare is a federal insurance program for people 65 and older, some young people with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or transplantation.

Since Medicare is a government program, the insurance plan can be a bit more complex than private policies . In this sense, legislators have decided to divide it into different parts in order to meet more specific needs and reduce costs. We will see some of them below.

• What to do if your doctor does not accept Medicare?
• Can I deduct Medicare from my taxes?
• Does Medicaid cover braces?

Medicare Hospital Insurance (Part A)

Medicare Part A is responsible for covering hospital stays , as well as paying for a large part of the facilities and services for nursing, hospital care and other types of professional care related to the health area.

Medicare Premium (Parte B)

Part B of this program is called Medicare Premium and, thanks to it, users can receive services from doctors, emergency care, medical supplies and other preventive services that allow a better state of health.

Medicare Advantage (Part C)

Although Medicare plans A and B cover the most essential costs of health insurance, Part C is aimed at closing the gap in the amounts that Medicare covers . Typically these do not tend to be very high and more difficult medical illness cases tend to consume the value more quickly.

Medicare Part D.

Medicare Part D is aimed at covering the drugs that the patient will consume . While it is not usually the highest of costs in the case of the flu, people who need more expensive and difficult treatments can find it difficult to cover them.

Medicaid

It is important not to confuse Medicare and Medicaid. If you still have questions, we leave you our content on what are the differences between Medicaid and Medicare .

The Medicare health coverage program is aimed at meeting the medical needs of millions of Americans, including low-income people, adults, children, pregnant women , older adults , and people with disabilities .

Medicaid is normally administered directly by the states, but they must follow the guidelines established at the federal level . This program is funded by the states and the federal government. This can be a bit confusing for some people, because they often have different names. However, we will show you below.

Medicaid by state

Medicaid Name by State
State	Medicaid Name
California	Medical
New York	NY State of Health
Texas	STAR managed care program
Florida	Florida Statewide Medicaid Managed Care
New Jersey	NJ FamilyCare

Children’s Health Insurance Program (CHIP)

The CHIP Program is for children who need coverage . Thanks to federal support, this plan offers low-cost coverage so that children from families that do not earn much money can qualify for Medicaid, as well as pregnant women and some other exceptional cases.

According to current legislation, CHIP is offered through each state and works in conjunction with the Medicaid program . In this sense, children have access to free dental and pediatric visits. And although the price is different in each state, the system is designed so that no more than 5% of the family's annual income is paid.

Health Insurance for Military and Veterans

There are several options for active duty military personnel, veterans, and their families. Normally, people who work or worked in the military are covered by the TRICARE program or under the health care program for veterans , under the provisions of the Health Care Law.

If not, there are a few different health coverage options , such as the VA Civilian Health and Medical Program (CHAMPVA), the Spina bifida health care benefits program, or any of the specially priced private health insurance options.

Indian Health Service

Indigenous people or direct descendants can access health coverage services provided by the Indian Health Service , an institution created by the federal government for this purpose.

Supplemental coverage

In some cases, both public and private insurance do not include some concepts. In this sense, there are supplementary coverages that help fill that gap in the coverage of medical expenses . Here are some options that can help you find a solution.

Medigap (Medicare Supplement Insurance)

Medigap is Medicare Supplement Insurance that is responsible for helping to fill the gaps in coverage provided by government insurance . This part is covered and marketed by private companies with the intention of helping pay for remaining expenses, such as coinsurance, copays, and deductibles.

In addition, Medigap covers some services that are not covered by Original Medicare, such as medical services out of the country . And although we show you the most common policies above, Medigap has 12 different options that are responsible for providing specific medical coverage. Here we show you each one of them:

• Plan A
• Plan B
• Plan C
• Plan D
• Plan F
• High deductible plan F
• Plan G
• High deductible plan G
• Plan K
• Plan L
• Plan M
• Plan N

Hospital indemnity insurance

The insurance indemnity hospital is a medical insurance coverage that pays for benefits only in case of hospitalization . While traditional insurance pays for medical services after meeting deductibles, coinsurance and copayments, hospital indemnity insurance will make all the payments regardless of any other coverage you have.

In this case, all the plans are usually different. Some of the most common concepts that they usually cover in a fixed way are the following :

• Hospital admission
• Overnight stay
• Intensive care unit
• Emergency room
• Outdoor procedures
• And sometimes even specific illnesses or accidents

Dental insurance

Because health insurance does not always include dental health services, dental insurance plans help people preventively cover the costs of their dental health care and undergo treatments such as crowns, bridges, and other area procedures. Normally, dentists tend to have a high cost in the USA and in this way the expenses related to this concept can be controlled.

The best dental insurance plans tend to provide access to a larger network of dentists, offer larger benefits annually, and lower premiums . In this sense, it is important to take into account the aspects that we mentioned.

Dental insurance by state

• Dental insurance in Texas
• Dental insurance in New York
• Dental insurance in California
• Dental insurance in Florida
• Dental insurance in New Jersey
• Dental insurance in Georgia
• Maryland dental insurance
• Massachusetts dental insurance

Vision insurance

Vision insurance is a special type of insurance that is usually paid for separately and covers all vision-related concepts that are not normally included in the standard insurance plan. Among the benefits they include are eye exams, ophthalmic visits, contact lenses and eye prescriptions.

Vision insurance may also give you discounts on certain specific corrective vision surgeries . This is a pretty good benefit, as you still have to make copays and pay deductibles.

Health insurance for specific diseases

Health insurance for specific diseases are supplementary policies that will only cover you if you are diagnosed with a particular disease , which is specified in the policy, such as cancer , Alzheimer's or heart problems.

These insurances are not that comprehensive and do not have very extensive medical coverage, so it is important that you understand exactly what the insurance covers and what the insurance does not cover . You must be careful when considering whether you are at risk of developing the disease due to a genetic predisposition or professional dangers.

It is important to consider whether you are taking on a new financial burden for a considerable possibility or if you are buying out of excitement or fear.

Insurers that offer health insurance for specific diseases

• Cigna
• Health Net
• Human
• Molina Healthcare
• United Healthcare
• American Family Life Assurance Company (AFLAC)
• Ambetter Health Insurance: Comments and Reviews

Alternatives to health insurance

Many countries have adopted a universal healthcare system . This means that the government is in charge of covering health expenses, as is the case with education or defense. It's like expanding Medicare or Medicaid to everyone. For example, when Canadians go to the doctor, the government pays a large part - or all - of the bill.

The downside is that it could take a great deal of time to see the specialist or receive a non-emergency operation . However, no one has to worry about dying from a disease because they cannot access treatment.

When Hillarycare tried to implement universal healthcare in the US, the medical profession and health insurance companies opposed it. Obamacare was initially introduced as a universal health care plan . However, different stakeholder groups and politicians guided the negotiations to a point where they changed the initial goal.

Access to health has become one of the most platonic American dreams . In fact, research has found that the better an individual's income, the better health they are. As a result, an unimaginable health inequity has been created in the country.

Here are some alternatives you can turn to to get better health care without requiring traditional insurance options.

Direct Primary Care Memberships

Direct Primary Care memberships are a financial agreement that is made directly between the patient and the healthcare provider . Thanks to this, insurance companies are left out of the process and there is no need to introduce health claims. As a consequence, the costs go down a lot.

One of the benefits of receiving direct primary care is that you do not have to pay monthly premiums or copayments . Instead, a monthly fee must be paid to the healthcare provider directly.

However, there are also negative aspects. Probably the biggest one is that it is not health insurance as such, but is more like a high deductible health plan . In this sense, the costs of deductibles increase greatly.

Advantages and disadvantages of primary medical care
Advantage	Disadvantages
Less waste of time and paperwork	Some concepts are not covered
Advance payments	Membership does not count as a deductible
Accessibility and convenience

Medical cost-sharing programs

Medical cost-sharing programs have been becoming increasingly popular in the United States , especially since faith centers run and promote them. And it is that these programs offer coverage of medical expenses with only paying a monthly "share" -which would be equivalent to a premium.

In addition, they are based on principles and values ​​that are shared among the different people that make up the faith center , unlike the risk-sharing nature of health insurance.

In practice, these programs are often much cheaper than traditional health insurance . As a result, families can become members for a monthly amount that varies between $ 300 and $ 500. When this amount is compared to the $ 1,500 per month insurance charges on average, it can be quite attractive. This is not to mention that the out-of-pocket expenses are also usually less than the deductibles of the insurers.

However, as it is not health insurance as such, your coverage could be more limited, both for handling costs and claims , as well as for tax reimbursement. Similarly, covered medical expenses must be “biblical,” which means that concepts such as birth control, abortions, and injuries related to alcohol, drug use, or dangerous activities are excluded.

To acquire a membership in a health cost-sharing program, the center may require a signed agreement with a statement of faith , and in some cases you may even have to verify your attendance at the faith center - although this does not happen in all cases. cases.

Health Savings Accounts

The Health Savings Account (HSA) is an account that allows you to save pre-tax dollars to cover qualifying medical expenses . This money can be invested in tax-free mutual funds without expiration.

HSA plans are exclusively for individuals who qualify for a high deductible health insurance plan or a consumer-choice health plan . However, HSA accounts are not covered beyond qualifying medical plans, cannot be claimed on dependents' tax returns, and do not receive the last three months of Veterans Affairs benefits.

Discount cards for medical services

Discount cards for medical services provide individuals with free service fees without being insurance as such . Members and their families can participate in different discount programs and networks to reduce their out of pocket expenses in concepts such as the following.

• Medical prescriptions
• Dental care
• Hearing care
• chiropractic
• Vision care
• Telemedicine
• Nursing
• Diabetes
• Nutritional supplements and vitamins
• Chiropody
• And more

Short-term health policies

The Health Insurance Short-term are a type of insurance plan that can provide medical coverage when the beneficiary is changing health plans , it is outside the registration period or if you need coverage in case an emergency occurs.

These coverages vary widely depending on the plan and the insurer with which the contract is signed . These plans do not require compliance with the guidelines established in the ACA law, so it is important to pay attention to the minimum amounts of coverage.

Short-term health insurance typically has some coverage for preventive care and doctor visits, as well as urgent and emergency care . Some plans also offer lower costs as long as a network provider is selected. However, it is important to read the exclusions and limitations before signing any document.

Policies with high deductibles

The High Deductible Health Plan is an insurance policy that has a higher deductible than traditional insurance policies . And although the premiums are usually less expensive, it usually takes a higher amount for the insurance company to do its part. These plans can be combined with HSA health savings accounts (mentioned above), so you may be able to pay for certain medical expenses with pre-tax money.

In 2021, the IRS defined High Deductible Health Plans as those with a deductible that cost $ 1,400 for an individual and $ 2,800 for a family . The total annual amount of out-of-pocket expenses, including deductibles, coinsurance, and copayments, cannot exceed $ 7,000 per person and $ 14,000 per family, but this does not apply to out-of-network services.

The amounts defined by the IRS for the year 2022 will be slightly different , although they will not vary in terms of deductibles. In this regard, it is expected that no more than $ 7,050 per individual and $ 14,100 per family will be paid out-of-pocket - again not counting out-of-network services.

Medical tourism

Although this is a little known term, there are people who do medical tourism . These are people who travel to other countries to receive any type of medical care at a fraction of the price and receiving a similar or better quality.

In 2007, the estimate of Americans who traveled to other countries was 750,000 per year. However, in 2017, this number increased to 1.4 million Americans , which represents approximately 10% of global medical tourism. This is because the United States has the most expensive healthcare system in the world and it is not very difficult to get the same procedures between 30% and 65% of the total amount that can be obtained in the USA.

According to Medical Tourism magazine , the 10 countries to which they travel the most for health reasons are:

• Canada
• Singapore
• Japan
• Spain
• United Kingdom
• Dubai
• Costa Rica
• Israel
• Abu Dhabi
• India

Medical insurance for the undocumented

If you are wondering how to access health insurance for the undocumented , the truth is that it can be a bit difficult, but not impossible . It is important to choose the correct state to live in and have sufficient resources to pay for it.

Normally, the available options are limited to private and expensive systems, but there are alternative possibilities and specific conditions that will allow you to access more easily . Remember that undocumented people cannot access the benefits of the ACA law, so you will not be able to obtain it at a reduced price.

The federal government and high-level authorities have been making a great effort to legislate on universal access to health insurance, but no conclusion has yet been reached. We hope to bring better news soon.

In summary

Health insurance in the USA is quite expensive and the price depends on a wide variety of factors, making it very individualized to the user . There are multiple ways to access health insurance, from private to public initiatives, as well as alternative formats that allow you to receive medical care.

Regardless of your decision, the ideal is that you compare the different options that are available . Evaluate the risks involved in each of the options and make an informed decision that is consistent with your possibilities.

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