Injury or illness can happen to anyone, anywhere. Unfortunately, in the USA, you will find yourself in deep financial trouble if you become injured or ill without insurance. Unlike many countries, the USA does not offer universal health insurance. Instead, workers are covered through private insurance companies that contract through employers. Your employer pays a certain amount of money, called a premium, each year for this insurance, and this is considered a benefit of working for that company. In some cases, people opt to purchase their own insurance, although that option is prohibitively expensive for most families.
Insurance policies
In exchange for the premiums, you will be issued a document called a policy. This policy is a contract that states what services the insurance company will pay for. Sometimes, the policy includes a list of specific health care providers from which you must choose. If you choose a provider who is not on the list, the insurance company may not pay the full amount for the services.
Insurance companies are regulated by state and federal laws, and these laws vary widely from state to state. This means that policies and coverage may be different from one state to another. If you plan on traveling, check your policy to make sure your coverage will follow you.
Suppose your policy states that the insurance company will pay for regular visits to a doctor, and you need your yearly physical exam. So, you go to your doctor and, instead of paying the doctor yourself, the insurance company pays for your physical. This involves filling out insurance forms at the doctor's office. If the doctor gives you a prescription, you will take it to your pharmacy to be filled. If your policy pays for prescription medicines, you will receive your medications at no charge.
Sounds easy, right?
Insurance language
Wrong. Most insurance policies are not that simple. They may require that you pay part of the fees for office visits and medications. This fee is called a co-payment, and is usually a minimal amount of money. In other words, if the physical exam costs $100, you might pay $10, and the insurance company pays the balance of $90. Sometimes, the patient is required to pay a set amount of money toward health care before the insurance begins to pay the bill. This set amount is called a deductible. For example, the policy might state that the first $100 of health costs must be paid by the patient, after which the additional expenses will be covered by the insurance company.
Sometimes, an insurance company won't cover particular services at all. These are called exclusions. Common exclusions are birth control pills, cosmetic surgery and other quality of life services. Some policies set a dollar limit for a particular service as well. For instance, the policy might cover two visits a year to a dentist, with an annual limit of $1,200 for treatment.
If you obtain a service that is not covered by your health plan, you will have to pay for it yourself.
There are many types of health insurance policies, and deductibles, exclusions and co-payments vary considerably with each type of policy and between insurance companies. These policies can be difficult to understand, as they are often quite complicated and confusing. Therefore, it is extremely important to read your policy carefully and completely.
For more help with insurance language, check out our health insurance glossary. If you're still confused about your policy, or insurance in general, ask your employer's benefits department or the insurance company representative.
Employment and insurance
Employers usually offer a variety of plans. For example, a single person might choose a plan that does not cover extensive services. But a married person with children would likely choose a family plan with more extensive coverage. The premiums for a more-limited plan are, of course, less expensive. Since most employers pay part of the premiums and you pay part of the premiums, it is to everyone's advantage that the employee chooses the plan that best suits her needs.
If you leave your job, you are entitled to continue your health insurance coverage for up to 18 months under a federal law called COBRA. The catch, however, is that you must pay the full amount of the premiums yourself. Hopefully, within that time, you will have secured another job and coverage from your new employer. If you don't have a new job, or you work at a company that doesn't provide health insurance, you can buy a policy for yourself and your family, but it is expensive.
In the end, the best way to deal with insurance in the USA is to stay healthy so you don't have to go to the doctor in the first place.
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