Medical Insurance

Health Insurance in the USA: Everything you need to know

Pinterest LinkedIn Tumblr

Health insurance in the USA today is nearly more important than you can imagine. Paying for medical expenses through social insurance, privately purchased insurance, or even a social welfare program helps a person get ahead in his life without issues.

In simple words, health insurance is nothing but coverage to help provide your medical bills. You can go for both social and private insurance programs to get the benefits. Of course, you will have different kinds of coverage and different premiums with other insurance companies.

Read also: What do Pregnant Women need to Know When Going Abroad? Travel Insurance Tips

Most employees get their health insurance policy from the company they are working in. But if you haven’t gotten it already, you might be looking to purchase your own from a private insurance company. The employer-sponsored insurance program will cover the specific amount of your premiums.

A premium is an amount that you must keep monthly to the Insurance company. It’s a way to keep your subscription active and eligible to get the insurance when in need. It somewhat depends upon the level of coverage you require. Selecting a good company for purchasing health insurance is not a tedious process. Understanding how these insurance policies work is actually where you should give most of the time.

What does the health insurance plan cover?

Health Insurance in the USA

The health care reform has brought a lot of standardization regarding insurance plan benefits for people. Before the standardization, the benefits varied vividly among different plans. Now minimal essential health benefits are included in most of the health insurance plans of the US. These are-

  • Hospitalization
  • Emergency services
  • Newborn care
  • Laboratory tests
  • Substance abuse
  • Outpatient care (services and doctors that follow outside the hospital)
  • Dental, vision care with pediatric services
  • Preventive services
  • Rehabilitation services
  • Prescribed drugs and pills
  • Mental health treatment

The cost of this coverage varies from one insurance company to another. Most of the amount is included in the premium you pay monthly. The additional amount comes up with co-pays, deductibles, and coinsurance when receiving health care. Read below to understand the depth of these terms.

Essential terms of insurance you should know

Health Insurance in the USA

Out-of-pocket expenses: healthcare being present, you still might be liable to pay some portion of the medical expenses. That particular amount is called out of pocket expenses. However, these are different from what you spend monthly in the name of premium.

Annual deductible: we shall read more on this later in the article; for now, a yearly deductible is something you pay annually before the insurer pays their share of the cost.

You will need to pay $1000 if your deductible is the same amount. It is only required by the time of receiving the health care services each year. The insurance company will pay its share after this.

Co-pay clause: It is the fixed amount you pay from yourself every time you come across a health care bill. If the co-pay is $50, you must spend that amount. The remaining amount will be paid by the company. You will get a lower co-pay if the premium of the insurance company is greater. Specific plans who don’t prefer co-pay go for other methods of sharing amount.

Coinsurance: The cost of your medical healthcare converted into a percentage is the co-insurance. If the bill cost you $1000, you might be required to pay 200 dollars (20%). The insurer does the rest of the 80%. Higher premium plans have lesser coinsurance.

Annual out-of-pocket maximum: The maximum cost-sharing on your liability for the year is the annual out of the pocket maximum. Except premiums it includes everything from co-insurance, copays, and deductibles.

After reaching the limit, the hundred percent of your cover cost will be taken by the insurance company to compensate for the remaining plan for the year. While most people cannot reach the limit easily, it is still a possibility if one undergoes a severe accident or costly treatment. Higher premium plans have lesser out-of-pocket limits.

What is deductible in health insurance?

Understanding the technicalities of the insurance industry can be challenging. Ignoring them and just going to purchase the first insurance policy you see is not bliss. To make the best choice for health insurance, you must understand the terms and regulations of the policy.

You might have heard about the term deductible when it comes to health insurance. This part will help you understand what a deductible is and how it works.

When an insurer pays a certain amount of the claim whenever necessary, it is called the deductible amount. The insurance company pays the remaining amount.

Read also: Get Free Health Insurance With These Tips

How does a deductible amount work?

There’s a specific decided amount for the deductible in every healthcare insurance. If the deductible amount in your plan is, let’s say, $1000, and you have the claim of $6000, you will pay $1000. That means the deductible amount, no matter how much it will come out of your pocket. The insurance company will handle the rest of the amount of the claim according to their plans.

On the other hand, if your claim is less than the deductible amount, the insurance company will be liable for nothing. For instance, If the deductible amount is $5000, and your health care claim is $3000, you will receive no money from the insurance policy.

These policies are only useful if the deductible amount is less than they claim.

Why care for deductible?

To understand it a better way, consider a child is given a toy and is warned ahead of the time that he will have to pay the price to fix it if he gets damaged. After hearing this a child will shortly be more careful while playing with the toy.

The child will not do anything to put the toy in a damaged condition because he will have to take the money from his piggy bank and pay for it. And that amount would be considered as deductible.

All insurance companies do this to put limitations on insurance from making small claims. It also lets the policyholder know that a certain amount of the claim will be paid from his pockets. This is important as people often make false claims or very unnecessary claims. When they realize they will be paying a certain amount, they will be careful with their claims. Therefore you should understand the structure of the deductible amount of the health insurance plan before your purchasing the policy.

Copayment in health insurance

Health Insurance in the USA

If you are sharing your medical expenses with the insurance, then you can call it a co-payment. Genuinely understanding the copayment concept is essential to know how much you will pay for medical bills.

For instance, consider a person who has a 5000 dollar insurance plan, and the co-payment clause is 20%. One day, because of an unfortunate event, he is rushed to the hospital to treat himself, and the hospital is charging $3000 in the medical bill. In this case, he will have to pay 20% of this bill from his own pockets while the insurer will manage the rest. That’s how the co-payment works.

The insurance applies the co-payment condition in different ways in different circumstances. Here are some of the scenarios where copayment could work-

Age factor

The copayment comes into light, especially with the senior citizens. It’s an honest opinion that health can degrade with time as a person ages. Older aged people can put frequent claims compared to others. Therefore the insurers put the payment clause on the policyholders to mitigate this risk after an age limit.


If a person wants to go with the hospital that is not connected with the insurance company, the insurer can put the co-payment clause. However, it may not happen if he goes with the hospital tied up with the insurance company.


The premium varies depending upon the region of the policyholder. The premium coverage will be much less for a person living in a village than someone from metro cities.

The insurer can also provide the co-payment of a person for treatment, even if the place changes. If the policyholder is living in a village or small city but goes for treatment in a metro city with expensive healthcare facilities, he can still benefit.


A co-pay clause can also be put by an insurer if a person having critical illness or pre-existing disease is getting a health plan. It is somewhat because expensive treatments need more money.

What is a covered benefit?

There are two different meanings for ‘covered’ and ‘covered benefit’ in the insurance industry. The covered benefit is a health insurance service included in the premium that the policyholder has to pay. Covered means the insurance company considers paying a portion of the allowable cost of the service. However, it is never a hundred percent amount.

For instance, an urgent care covered plan can be applicable for co-pay. Here co-pay will act as out of the pocket amount for the person having the policy. It works so that if the co-pay is $200, the policyholder will need to pay it for the health care service. Later on, the insurance plan will cover the amount in another urgent care service.

Write A Comment