Health insurance in the USA is not provided by the government for all citizens and also is not obligatory to have health insurance in the USA. But on the other hand, it is important to have health insurance because medically necessary health services can cost you a fortune. There are two types of insurance plans in the country: private and public. This means that you can purchase plans from private companies like Jersey Insurance or through government health exchanges. Health insurance provided by the government is through Medicare, Medicaid, or the Children’s Health Insurance program.
If you don’t have insurance that is provided by your employer or government you need to purchase it on your own.
Health insurance differs from Individual health insurance and Group health insurance.
INDIVIDUAL HEALTH INSURANCE
Individual health insurance is a type of coverage that you purchase on your own, and its coverage is not obtained by employer or state programs like Medicare, Medicaid, and CHIP, but rather through private companies. It is suited for everyone who doesn’t have access to health coverage sponsored by an employer or the government, including self-employed people, people who work in small companies, students, or those who quit working before the age of 65.
There are three main types of plans for individual health insurance that can be purchased, and they are:
- Affordable Care Act Plans (ACA; also known as Obamacare)
Medical Indemnity plans
There is also one special type of coverage in cases of catastrophic health issues that might occur in a lifetime – Critical Illness Insurance.
AFFORDABLE CARE ACT PLANS
These types of plans must fulfill requirements under ACA and they are the most extensive plans on the market. They have to cover a minimum of essential benefits for individual and family coverage. They are part of major medical health insurance plans and can also be purchased through licensed brokers. The good thing is that these plans have a large range of health providers and are available to almost everyone.
All ACA plans to provide these 10 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 and rehabilitative services.
The four main types of ACA Plans are HMOs, PPOs, EPOs, and POSs. There is also a Catastrophic plan which is designed for people under the age of 30.
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, people who are waiting to be eligible for Medicare, and those who missed enrollment period for ACA, etc. All of them aren’t part of major medical health insurance plans. This plan offers coverage for individuals and families for a short period and even though they are less expensive than ACA plans they also have fewer benefits. If these plans don’t fulfill ACA requirements your medical needs may be uncovered.
MEDICAL INDEMNITY PLANS
These plans are also known as fee-for-service plans. With these plans, 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 can be good for individuals who are looking for more flexibility in choosing doctors and hospitals they want to visit.
Also, it is worth mentioning that there is supplemental indemnity insurance which is designed to assist you financially in the moment of your hospitalization – Hospital Indemnity Insurance.
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, not individuals.
Businesses and organizations buy health insurance 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. This means that you will be insured regardless of any health issues you might be having.
It is important to know that small businesses under 50 full-time employees aren’t required to provide group health insurance. On the other hand, larger providers are required to do so.
TYPES OF GROUP HEALTH INSURANCE
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 PCP must get you a referral for specialists.
PPO – Preferred Provider Organization. With this plan there is no need for a 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.
EPO – Exclusive Provider Organization. With EPO you don’t need PCP, but you’ll maybe not 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.
Group health insurance also has metallic levels for plans. There are 4 types of metallic levels for every plan:
Platinum – those have the highest level of coverage, 90%. They have higher monthly premiums but lower out-of-pocket costs.
Gold – coverage is 80% but has higher copayments and premiums
Silver – covers 70% of the average costs of the beneficiary and has less expensive premiums
- Bronze – beneficiaries are paying the lowest amount of health expenses, just 60%, but have more affordable premiums.