Health Insurance

In the USA, health insurance is not provided by the government, and it is not obligatory to have health insurance in the USA. But it is important to have health insurance because, without any coverage for necessary health services that could be needed sometimes, you can end up paying a lot.

There are two types of insurance plans in the country: private and public. This means that you can purchase plans from private companies like Temmen Insurance or through government health exchanges (through Medicare, Medicaid, or the Children’s Health Insurance program).

Health insurance plans have 2 types of policies: Individual health insurance and Group health insurance.

INDIVIDUAL HEALTH INSURANCE

Individual health insurance is a type of coverage you purchase on your own, and its coverage is not obtained by employer or state programs like Medicare, Medicaid, and CHIP, but through private insurance companies. It is designed for any individual who doesn`t have access to health coverage from an employer or the government, including self-employed people and students. In general, it is a contract between the beneficiary and the insurance provider company where each party agrees to pay a determined price of premium and a determined percentage of medical expenses for each service provided.

There are 3 main types of plans for individual health insurance plans:

  • Affordable Care Act Plans (ACA plans)
  • Short-term plans
  • Medical Indemnity plans

AFFORDABLE CARE ACT PLANS

These plans must fulfill requirements under the Affordable Care Act from Obama`s administration in 2010, commonly known as Obamacare. ACA plans are the most extensive plans on the market. They are part of major medical health insurance plans and can also be purchased through licensed brokers. The biggest advantage is that ACA plans have a large range of health providers and are available to almost everyone.

All ACA plans provide these 9 things:

  • emergency services
  • hospitalization
  • out-of-patient services
  • maternity leave
  • prescription drugs
  • substance use for disorder services (like mental health and behavioral problems)
  • pediatric services (including oral vision and care)
  • preventive services for chronic illnesses
  • rehabilitative services.

The four main types of ACA Plans are HMOs, PPOs, EPOs, and POSs, explained below under the Group Health Insurance section. There is also a Catastrophic plan which is designed for people under the age of 30.

SHORT-TERM PLANS

Short-term plans are usually for individuals who are in transition periods, like students who need temporary coverage in the state where they are studying, unemployed people who are waiting for a job, etc. They are not part of major medical health insurance plans. This plan offer coverage for individuals and family for short period and even though they are less expensive than ACA plans they also have fewer benefits.

MEDICAL INDEMNITY PLANS

These plans are also known as fee-for-service plans. With Medical Indemnity Plan, you can see any doctor you want without a referral to a specialist. Also, you don’t need to choose a primary care physician with this plan. You may pay an annual deductible before the insurance company starts to pay for your needs. This type of plan is suited for individuals who are looking for more flexibility in choosing doctors and hospitals they want to visit.

GROUP HEALTH INSURANCE

Group health insurance is a type of insurance for employees and members of some company or organization. It provides coverage to its members at a lower cost. Only groups can buy this type of coverage, they are not available to individuals.

Businesses and organizations buy health plans for their employees or members. It is usually a type of insurance for small businesses (from 2 to 50 people). This insurance provides a lower cost than individual insurance because the risks are divided among the group itself. The good thing about group health insurance is that if your employer chooses it then it is available for everyone. Larger employers are required to provide group health insurance for their workers.

GROUP HEALTH INSURANCE PLAN TYPES

There are 4 main types of group plans: HMO, PPO, EPO, and POS.

HMO – Health Maintenance Organization plan. Every beneficiary must choose their primary care doctor and they must visit doctors within the HMOs network. Visiting out-of-network doctors may result in no coverage at all. Also, your Primary Care Physician (PCP) must get you a referral for specialists.

PPO – Preferred Provider Organization. With this plan there is no need for primary care doctor, so you can choose any doctor you want, but if you go to an out-of-network doctor you will have higher costs. There are no referrals needed to go see a specialist.

EPO – Exclusive Provider Organization. With EPO you don’t need Primary care Physician, but you maybe don’t get coverage if you visit an out-of-network doctor.

POS – Point of Service. Usually a combination of HMO and PPO plans. This means that you need to determine your, primary care doctor, for regular visits and to get a referral to see a specialist, but on the other hand, you’ll be able to see an out-of-network doctor.

 

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