Medical Insurance in the USA: Cost, Types, How to Get, Nuances

Medical Insurance in the USA Cost, Types, How to Get, Nuances

Health insurance is a contract with an insurance company under which you pay regular insurance premiums, and in return receive full or partial compensation for various medical services.

Until 2019, purchasing an insurance policy in the US was mandatory, and you would have to pay a fine if you didn’t have insurance. Since 2019, the requirement has been abolished at the state level, however, in some states, health insurance is mandatory.

Medicine in the United States is very expensive: from year to year, the United States ranks first among other countries in terms of the amount of medical expenses per person. For example, in 2019 this amount was $10,948. At the same time, state insurance programs in the United States are provided only for certain categories of citizens, so the issue of purchasing insurance is relevant for most residents of the country, unless the employer has provided insurance.

Note: Some companies provide insurance to employees. It may also include family members. Group insurance is also popular, when one insurance contract includes a group of employees of the same company.

Let’s find out what types of insurance there are in the USA, whether there is free medical insurance, how to purchase an insurance policy and how much it costs.

The cost of medical services in the USA

There are no free medical services in the US. Even emergency medical care requires payment. If you do not have an insurance policy, the costs will fall entirely on your shoulders. Let’s look at what the most popular medical services cost the residents of the country. The spread of prices for some services is quite large, this is due to the difference in prices in different clinics, as well as the difference in prices for variations of the same procedure (for example, a blood test can be both basic and complex).

  • Complete blood count: $4 – $83;
  • X-ray: $51 – $320;
  • Ultrasound $155 – $721;
  • MRI: $563 – $3074;
  • CT: $320 – $1869;
  • Appendectomy: $6,063 – $11,445
  • Tonsil removal: $2935 – $6189;
  • Natural birth: $4,032 – $10,037;
  • Physician visit: $42 – $170;
  • Cardiologist visit: $136 – $207.

Where to buy health insurance in the USA

The market and prices for insurance policies are controlled by the state, so you can purchase insurance on the state Healthcare portal. In addition, there are deadlines for purchasing insurance for the next year.

It is possible to purchase insurance outside the established period, but under certain circumstances, for example, loss of valid insurance, the birth of a child, a change of residence, and so on. Also, citizens under the Medicaid program (this is a state program for providing medical care for those in need) can apply for insurance at any time.

Types and categories of medical insurance in the USA

Categories of insurance

There are 4 categories of insurance, the difference between them is how much of the medical expenses the insurance company will pay, and how much you will pay. Depending on the height of coverage of expenses, the amount of the insurance premium for each category of the policy also differs.

  • Bronze: you pay 40%, the insurance company pays 60%;
  • Silver: you pay 30%, the insurance company pays 70%;
  • Gold: you pay 20%, the insurance company pays 80%;
  • Platinum: you pay 10%, the insurance company pays 90%.

All plans provide for a deductible – this is a certain amount, within which you pay all medical expenses yourself. The lowest deductible is in the Platinum category, which also has the highest insurance premium. You should also take into account that the amount of the insurance premium may depend on your income.

Insurance plans

Within each of the insurance categories, you can choose from several plans that differ in terms of coverage. Let’s look at the most common insurance plans and their differences.

An EPO is a plan in which the insurance company covers you for medical costs only in a certain network of medical facilities (excluding ambulances).

An HMO is a plan that pays you when you get health care services from doctors who work or contract with a particular health care organization (excluding ambulances).

A POS plan covers both in-network and out-of-network medical services, but in the first case, your share of the payment for services will be less than if you contact specialists from other institutions. Also, one of the conditions of this plan is a mandatory referral from your family doctor in case you need to see a specialist.

Having a PPO plan means you can contact both doctors within a certain network and specialists from other clinics and diagnostic centers, but in the first case, your part of the payment will be less. This type of plan does not require a referral from a family doctor to see subspecialists.

Things to keep in mind when choosing an insurance policy

When buying an insurance policy, you will need to choose the most advantageous plan and category, as the final cost of your treatment will depend on this. The category determines what percentage of the cost of medical services will fall on your shoulders, and it depends on the plan whether you can be treated at the medical facility of your choice without additional payments.

Regardless of the type of health insurance and plan, health insurance policies in the United States cover the following types of medical services: outpatient care, emergency care, inpatient care, pregnancy and childbirth support, mental health treatment, rehabilitation, clinical tests, chronic disease management, drug coverage , services of pediatricians.

Other types of services, such as dentistry or eye care, are optional, but some types of plans cover optional services as well. It is also possible to purchase separate medical insurance, for example, for dental treatment, if you need it.

How much does insurance cost in the USA

When choosing an insurance policy, calculate the total cost of medical insurance. It will consist not only of monthly payments. Additional costs can amount to a significant amount, sometimes even exceeding the regular insurance premium. What additional costs should be taken into account? Firstly, the size of the deductible – specify it when choosing a policy.

In addition to the deductible, the insurance contract may include coinsurance or copayments – if so, then you will share the payment for medical services together with the insurance company, in a percentage or in the form of fixed amounts.

Note: It is also important to find out what is the maximum amount of your own payments in your insurance contract – many insurance contracts provide for a certain maximum payment per year, beyond which you will not have to pay anything.

The price of health insurance will depend on the region, your age and income. You can buy insurance for yourself as well as for your family. Let’s take a look at the average health insurance prices in the state of Georgia.

The insurance with the lowest monthly payment is in the Bronze category, HMO plan. The monthly installment in this case will be equal to $301. The deductible is $8,700 and your own payout limit is also $8,700. Diagnosis, GP or specialist visits, and prescription drug purchases are free of charge if you get services at one of the network facilities to which this plan is linked.

The insurance with the highest monthly payment in this region is in the Gold category, HMO plan. The premium is $581 per month, the deductible is $1,000, and your maximum payout is $7,500 per year. This plan includes copayment for certain types of services: for example, you will pay $10 for a visit to a general practitioner online, $35 to a narrow specialist, and $65 for an x-ray. When buying drugs, you will pay from $2 to 40% of the cost of the drug, depending on its category.