How Health Insurance in the U.S. work – Statistics and Facts

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Getting health insurance is an excellent choice for persons who do not want to deal with expensive medical bills. However, most health insurance remains unaffordable for most people in the world. For instance, research conducted by the Commonwealth in the first six months of 2020 showed that about 43.4% of U.S. citizens aged between 19 and 64 were not adequately insured. Also, the rate of uninsured adults was approximately 12.5%. Typically, this showing that more than half of the U.S. citizens struggle with health insurance. 

A survey conducted by the American Community Survey (ACS) revealed that people preferred private health insurance to public health insurance with 68.0% and 34.1%, respectively. However, a worrying factor is that health insurance plan rates have increased significantly during the past decade—this creating concern about the affordability of health insurance coverage in the United States.

What is Covered Under a Health Insurance Plan?

Unlike before, when different insurance companies offered various benefits, the Affordable Care Act (enacted in 2010) brought in the standardization aspect. This led to an obligatory number of health benefits to be offered by every plan, such as:

  • Prescription drugs
  • Rehabilitation services
  • Laboratory tests
  • Pediatric, vision, and dental care services. 
  • Hospitalization
  • Outpatient services
  • Mental health treatment
  • Substance-abuse treatment
  • Immunization
  • Maternity and newborn services.

Types of Health Plans Available in the U.S.

There are a variety of choices when shopping for health insurance. Nonetheless, the most common options are buying from an insurance broker or the U.S. marketplace. Different health plans have various levels based on the benefits they provide. Typically, the levels are bronze, silver, gold, platinum, and catastrophic. The cost-sharing aspect is the main reason why the different levels vary.

Bronze: The level provides 60% of your medical expenses while you cater for 40%.

Silver: The level covers 70% of your medical expenses while you are responsible for 30%.

Gold: The level covers 80% of your medicals while you pay for 20%.

Platinum: The level caters for 90% of your plan while you pay for 10%.

Catastrophic: This level is mainly allowed for individuals under 30 years.  You pay for the plan after reaching a deductible of about $8150 (as of 2020). They cover the first three initial visits and the preventive care at no cost, regardless of whether you are done with the deductible.

Here are the most common plans found in most insurance brands:

  • Health Maintenance Organization (HMO)

Under HMO, all services are delivered through a system of healthcare providers and amenities. The plan only allows treatment done by doctors in the network. In case you receive treatment from other doctors, then you will have to cater for your bill. Also, note that emergency treatments in facilities not in an HMO network must work within HMO rates. This is what you should anticipate under the HMO plan:

  • Less freedom when choosing a healthcare provider
  • Less paperwork than in other plans
  • You will have a doctor to manage your primary care who will refer you to specialists if need be. Note that under HMO, you must have a referral from a doctor before seeing a specialist.

Preferred Provider Organization(PPO)

In a PPO plan, you have the choice of seeing a provider out of your network but with higher rates. Here is what you get for a PPO plan:

  • You have moderate freedom when choosing your health care provider. Unlike the HMO plan, with PPO, you don’t need a referral to see a specialist.
  • You will incur a higher cost when you see a provider outside the network than an in-network provider.
  • Lots of paperwork than other plans, especially you seek care from an out-of-network provider.

Exclusive Provider Organization (EPO)

Under an Exclusive Provider Organization plan, this is what you should expect.

  • You have a moderate ability to choose your healthcare provider. Thus you need not follow any form of hierarchy to access your preferred doctor/specialist.
  • The plan does not cover any care done outside the network. It is only allowed if it is an emergency. In case you go for an out-of-network provider, you will have to pay for the bill.
  • It is a lower premium compared to PPO.

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Expatriate Health insurance

Whether you are in the United States for a limited or permanent period, you are eligible for a health insurance plan. Expatriate medical insurance enables you to access the best medical care when working or living outside your native country. Choosing the best expatriates insurance cover in the United States depends on your specific needs. Before deciding on a certain insurance cover, consider aspects such as what you need to be covered, your income, past medical history, number of people you want to be insured, etc.  

Bottom Line

A medical insurance cover in the United States helps you cut on costs on any future medical bills. However, the affordability rate of insurance plans in the United States is low, creating a point of concern. Even with the Affordable Care Act, which has changed how each insurance plan operates, much still needs to be done to make the insurance rates more affordable. However, U.S. citizens and expatriates still have different plans to choose from to cater to an unknown future’s health.