Navigating the Health Insurance Maze
By Paul Natinsky
Obtaining health insurance and using the coverage once insured is complicated even for English speakers who were born in the United States. It gets more confusing for non-English speakers, and still more puzzling for those new to the country.
Most U.S. citizens, and legal immigrants working for U.S. companies, have health insurance through their employers. These plans differ significantly in what services are covered and how much the patient has to pay.
How it works
Several terms are important to know here.
The premium is the amount of money patients and their employers pay each month for coverage. This amount varies depending on the types of services covered by the plan. Typically, the employer pays all or most of the premium. If employees are required to pay a portion of the premium, usually it is deducted from their paycheck.
Once employees are enrolled and issued an insurance card they may make appointments with doctors, visit the hospital if necessary, and receive other services. At this point, patients will encounter three new terms: co-pay, deductible and out-of-pocket maximum. These terms go together because they are part of the same equation.
The co-pay is pretty simple. It is the part of the medical bill that the patient pays, typically a percentage. So, for example if a doctor’s bill is $100 and the co-pay is 20%, the insurance plan pays $80 and the patient pays $20.
Looking at the next term—deductible—is where things begin to get complicated. In many plans, patients are required to pay 100% of medical bills until the total of their bills adds up to a certain amount, often several thousand dollars. Once the patient has “satisfied” the deductible, say it’s $4,000, then the insurance company begins paying 80% and the patient the remaining 20%.
This brings us to the out-of-pocket maximum, an amount significantly higher than the deductible. After a patient spends a certain amount of money, let’s say $7,500 on health services, including copays, services are covered 100%.
As if things are not complicated enough, every plan is different. The details of insurance plans are the results of negotiations between the employer and the insurance company. So, plans through the same insurance company for two different employers are likely to have different co-pays, deductibles, and out-of-pocket maximums—and cover different services.
Dental and Vision
In many cases, the health insurance plan does not cover dental care or vision/eyeglasses. Those services are covered under separate plans…and they generally don’t operate like health coverage.
Routine care such as checkups, dental cleanings, and eye exams is greatly discounted for patients. Significant dental work, such as fillings and crowns and eyeglasses, are typically covered with a co-pay up to a certain amount. Once that limit is reached, patients are usually responsible for any additional dental services or eyeglass costs until the next coverage year begins.
So, health care costs are usually limited for patients, while dental and vision coverage give patients an allowance with any additional costs going to the patient.
Confused? Don’t feel bad. Most people are perplexed by this puzzle. The bad news is that things get more complicated.
Networks
Health care, dental, and vision services are subject to “networks,” which are groups of doctors, dentists, eye care centers, and other professionals who agree to receive a discounted fee from the insurance company in exchange for the volume of patients the health care professional receives from being part of the network.
The insurance company passes on a portion of this discount to the patient. So, patients pay a lower fee when they use “in-network” professionals.
Most people in the United States have employer-sponsored insurance. But what about people who don’t work or whose employer doesn’t offer health insurance? People in these situations can receive coverage from a number of different sources.
Government Programs
Those who are below a certain income level or who have a disability can get coverage from Medicaid, a cooperative state and federal program administered by individual states. That’s right, more complexity. Each state has its own Medicaid program with different rules and coverages.
People who work for employers that don’t offer insurance can get federally subsidized plans through healthcare.gov. These plans operate a lot like private insurance, but are less expensive because the federal government pays most of the cost. Healthcare.gov plans are subject to income limits and the unavailability of employer-sponsored options.
For people older than 65, the federal government offers a comprehensive plan under the Medicare program. The patient portion of the premium is low and most services are covered. Inexpensive “supplemental” plans offered by private insurers cover what Medicare doesn’t.
For these public programs, there is a crazy quilt of regulations about eligibility, coverages, and other aspects.
For those who have refugee status, are undocumented immigrants, or have other special circumstances, non-profit organizations, immigration lawyers, and other resources are available to help navigate this intricate maze.
The system is complicated and in need of reform to make it easier for patients and able to cover more people. Until that day everyone will continue to try and keep pace.