What You Need to Know About Health Insurance in the USA

USA Health Insurance: where to start choosing

Everyone who cares about their health wants to receive quality treatment. In the USA, there is no mandatory health insurance program, so medical assistance can be quite expensive.

In this article, we will tell you about the most popular types of health insurance in the USA, the costs, which depend on many factors, and how to choose the most suitable plan.

Is it necessary to have health insurance?

Healthcare in the USA can be very expensive. Without insurance, you risk being left without necessary care or receiving only a minimal examination at free clinics. Signing a contract with an insurance company and purchasing a medical policy protects you from such unpleasant situations. Moreover, according to the recent healthcare reform, Affordable Care Act, you are required to have health insurance if you have been legally residing in the USA for a long time (studying or working) in the USA.

You can choose a comprehensive insurance package or partial coverage, as well as seek assistance from the government. Subsidies are available for people with low income. Additionally, your employer may cover the cost of health insurance if you get a job.

Types and Plans of Health Insurance in the USA

Types of Health Insurance

• Health Maintenance Organizations (HMO) (MediCal in California)
  This is the cheapest option. Services are provided only within a single network of medical institutions. The list of specialists and clinics in HMO is limited. To visit a required specialist, you must get a referral from the attached primary care physician. It only covers consultations with doctors within this network.
• Preferred Provider Organizations (PPO)
  The most expensive but very advantageous option. An extensive network of medical institutions collaborating with many other healthcare providers. Treatment can be received outside of PPO, and no referral is required for that.
• Point of Service (POS) and Exclusive Provider Organizations (EPO)
  These offer a limited range of services with cheaper doctors.

How to Choose a Plan?

Health insurance in the USA offers a variety of plans, depending on how much of the costs are covered by the insurance company. There are five main types of insurance plans:

1. 01. Platinum — covers 90% of medical expenses.
2. 02. Gold — reimburses about 80% of expenses.
3. 03. Silver — covers up to 70% of expenses.
4. 04. Bronze — reimburses 60% of the costs incurred.
5. 05. Minimal — provides coverage only for emergency situations, intended for people under 30 or with limited financial resources.

Each of these plans has its own advantages and disadvantages, and the choice depends on your individual needs, health, and financial circumstances.

Important Terms and Definitions

When choosing health insurance, pay attention to several key factors:

• Co-pay — a fixed payment for each service, with the remaining costs covered by the insurance company.
• Deductible — the amount you need to pay out of pocket before the insurance starts covering expenses.
• Co-insurance — you pay a certain percentage of the medical costs (as specified in the contract), with the remaining amount covered by the insurance.
• Out of Pocket Maximum — the maximum amount you can spend in a year. Once this amount is reached, the insurance covers all subsequent medical costs 100%.
• Coverage — the medical services covered by the insurance. Some plans may not cover dental, ophthalmological services, mental health treatment, or other specialized services.

Dental and Ophthalmological Services

It is important to note that dental and ophthalmological services are only included in insurance for children. If you want these services for adults, you will need to choose a corresponding plan or add these services separately.

How and where to buy health insurance

Let's figure out how to properly buy health insurance, which platforms you can use, and what deadlines to consider.

When to Buy

For most people in the USA, there are two main periods when you can apply for insurance:

• Open Enrollment Period — this is the time when anyone can apply for insurance through the Health Insurance Marketplace. This period generally starts in November and lasts until mid-December (exact dates change every year). In 2025, for example, the open enrollment period will be from November 15 to December 15. If you miss this period, you will have to wait until next year, except in case of special circumstances.
• Special Enrollment Period — this period is available for people who are eligible to apply at any time. This may be due to changes in family status (e.g., marriage or divorce), loss of employment, change in income, or other circumstances that allow you to apply for insurance outside of the open enrollment period. This period lasts 60 days from the date the circumstances change.

Where to Buy

There are several main ways to purchase health insurance in the USA:

1. 01. Health Insurance Marketplace
   This is the official site for purchasing health insurance, provided by the federal government: HealthCare.gov. On this site, you can choose a plan that fits your budget and needs. It is also important to note that this portal can show if you are eligible for subsidies (financial assistance) if your income is low.
2. 02. State Marketplaces
   Some states have their own online platforms for purchasing insurance, separate from the federal marketplace. For example, in California it is Covered California, in New York — NY State of Health, and in Massachusetts — Massachusetts Health Connector. If you live in a state with its own marketplace, this may be a more convenient way to obtain insurance.
3. 03. Direct Contact with Private Insurance Companies
   You can also contact private insurance companies directly, such as Blue Cross Blue Shield, Aetna, Cigna, and others. This may be a convenient option if you want a more personalized approach and access to private plans that may not be available through the Marketplace.

What Documents and Information Are Needed

To apply for health insurance, you will need to provide several key pieces of information:

• Personal Information — your name, address, date of birth, and SSN (or equivalent identification number).
• Income Information — this is needed to determine if you are eligible for subsidies and what plan will be offered to you.
• Family Information — if you want to add your spouse or children to the policy, you will need to provide their details.
• Health History — in some cases, insurance companies may ask for information about your current health status.

Cost of health insurance

The cost of health insurance can vary depending on many factors. Here are the key factors to consider:

• Plan Type
  The more comprehensive the plan (for example, with a low deductible), the more expensive the insurance will be.
• Age
  Health insurance is generally cheaper for younger people.
• Family Status
  For families, insurance will cost more than for singles, due to the inclusion of children in the plan.
• Location
  The cost of health insurance may vary depending on the state.

Typically, the average cost of health insurance ranges from $300 to $600 per month for one person. For family plans, the cost can be significantly higher depending on the coverage.

Tips for Choosing a Health Insurance Plan

1. 01. Assess Your Needs
   If you have chronic conditions, choose plans with lower deductibles and larger coverage.
2. 02. Check Doctors and Clinics
   Some insurance plans limit the choice of doctors. Make sure your doctor and nearby clinics are included in your plan’s network.
3. 03. Don’t Forget About Medications
   If you take medications, make sure they are included in the covered prescriptions list.
4. 04. Consider Subsidies

   If your income is below a certain level, you may be eligible for subsidies through the Health Insurance Marketplace. This can significantly reduce your health insurance costs.

Why Is It Important to Have Health Insurance in the USA?

Without health insurance in the USA, you may face very high medical costs. For example, a regular visit to the doctor can cost anywhere from $100 to $200, and hospital treatment can cost tens of thousands of dollars. Without insurance, such expenses can easily lead to financial ruin.

In addition, insurance in the USA gives you access to better and more diverse medical services. Insurance companies work with the best clinics and ensure their clients have access to top-tier specialists.