How the U.S. Health Insurance Works

Health care in the US is expected to be very expensive and manage circumstances like the people met with an accident and get injured. At this time, the cost incurred is more and how much care they require is unpredictable. In this case, US health insurance provides a way to minimize such expenses to more reasonable amounts. All information is briefly discussed below, and every insurance plan has different rules, so while deciding on the insurance plans, ask the three following questions and choose the one that will work best.

Where to acquire care?

Health insurance plans to be cost-efficient are to convince providers, including laboratories, physicians, pharmacies, hospitals, and other entities. Various insurance companies get commitment with a particular network of providers who have accepted to provide services to plan enrollment at more considerable pricing.

If a provider is not from the plan’s network, the insurance company may pay a small portion for the services provided or prefer not to pay altogether. It means the enrollee would be required to pay a much higher share of the cost who proceed from the outside of the network’s plan for care. It is a crucial concept to learn, especially for those not originally from the US.

What does the plan unfold?

According to the Affordable Care Act, the health care reform has introduced more standardization in insurance plan benefits in the US. Before introducing such standardization, the service offered varied significantly from plan to plan, like if some plans covered prescriptions whereas others did not. But currently, in the US, they are required to provide numerous essential health benefits that include:

·        Hospitalization

·        Maternity and newborn care

·        Emergency services

·        Laboratory tests

·        Outpatient care

·        Preventive services like management of chronic disease example, some immunizations

·        Mental health and substance abuse treatment

·        Prescription drugs

·        Dental and vision care, i.e., pediatric services

·        Rehabilitation services

How much will the cost be incurred?

It is a complicated task to learn about the insurance coverage costs. In the above brief discussion, paying a premium to enroll in a plan is understood. But it is an advanced cost evident to people who are aware of how much they pay. But sadly, it is not the only cost connected with the care people receive in most of the plans. When people access care, there is also another typical cost included in it. Such cost is apprehended as sustainable, copays, or coinsurance that defines the share paid from the person’s pocket when the care is received.

It is a general rule that the less it is paid in premium, the more pay is received when the care is accessed. And the more is paid in premium; the less pay is obtained when the care is accessed.

Important insurance terms and concepts:

Out of pocket expenditures: It is the part of the medical expenses that individuals wholly responsible for paying when they receive health care. However, the monthly premium payment for care is different from these costs. It is known as out-of-pocket expenditures or cost-sharing.

  • Yearly deductible:

In yearly deductible, a person pays for each plan a year before the insurance company begins paying its share of the costs. If the deductible is $2,000, the person is accountable for paying the initial $2,000 in health care they obtain each year, later which the insurance company begins to pay its share.

  • Copay or copayment:

The copayment is fixed, i.e., the upfront amount the person pays each time; they will obtain care when that care is concerned with a copay. Like, a copay of $30 might be significant for a doctor’s visit, later which the insurance company takes up the rest. Plans with lower premiums generally have higher copays and vice-versa. Typically if the plans do not have copays, they would use other methods of cost-sharing.

  • Coinsurance:

Coinsurance is a ratio of the cost of medical care. For example, the total cost for an MRI is $1000, and the person would pay $200 only 20% percent of it, and the remaining 80%, i.e., $800, is covered by the insurance company. Plans with higher premiums are expected to have low coinsurance

  • Yearly out of pocket maximum:

The yearly out-of-pocket maximum is the most cost-sharing the person is responsible for annually. It is the total of the person’s coinsurance (excluding premiums) and deductibles. Once the person reaches this limit, the insurance company will take up 100% of the person’s covered costs for the remainder of the plan year. Most of the enrollees fail to hit the out-of-pocket limit, but it is expected to happen if a lot of costly treatment is needed for illness or any severe accident. Plans that have higher premiums usually have lower out-of-pocket limits.

Different types of health insurance plans:

Health insurance plans vary. Each individual pays a share of costs for the standard enrolled person. Furtherly, deductibles, the amount the person pays before their plan, takes up to 100 percent of their health care costs; it varies according to the plan—usually the least expensive holding the highest deductible. The chart of US health insurance plans includes

Platinum plan: It covers 90 percent on average of their medical costs. They pay 10%

Gold plan: It covers 80 percent on average of their medical costs. They pay 20%

Silver plan: It covers 70 percent on average of their medical costs. They pay 30%

Bronze plan: It covers 60 percent on average of their medical costs. They pay 40%

Catastrophic plans: In the catastrophic plans, they must cover the first three preventive care visits and primary care for free, even they have not yet reached their deductible

HMO (Health Maintenance Organization):

An HMO offers all health care services through a health care provider network and facilities. With an HMO, they may have:

  • Compared to other plans least amount of paperwork required
  • Least freedom to select their health care providers
  • A primary care doctor to manage their care and refer them to specialists when they need one. So the care is covered using the health plan, But before they see a specialist, most of the HMOs will require a referral.


The above are some extensive information regarding the US health insurance plans. All the benefits, essential terms, concepts, cost incurred, and insurance plans are discussed to make a wise decision while choosing a health insurance plan.