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USA: Insurance and payment

In the USA, treatment costs are mostly paid by insurance: employer plans, the ACA marketplace (HealthCare.gov), Medicare and Medicaid.

Last updated: ~1 min read
On a dark navy background, an insurance card.
Figure 1.Card — USA: Insurance and payment

01Short answer

Under the ACA, plans cannot refuse you or charge more because of an existing illness. Every plan has a yearly out-of-pocket maximum; after it, covered in-network services are usually paid in full. The deductible, copays and coinsurance set your share. Out-of-network care can be very expensive; the No Surprises Act protects against some surprise bills. People with low income may qualify for Medicaid, and people over 65 for Medicare.

02Simple explanation

Existing illness: not a reason to refuse.

Out-of-pocket max: a yearly cap.

Network: matters.

03Scientific explanation

Enrolment: ACA plans are usually joined in the yearly open enrolment, or in a special period after events such as losing a job.

Transparency: hospitals must publish their prices.

04What happens in the body?

Card

Check the plan type on your card (HMO, PPO).

Network

Confirm the doctor and hospital are in network.

On a dark navy background, dots on a map.
Figure 2.Network — USA: Insurance and payment

EOB

Compare the insurer’s explanation with the hospital bill.

On a dark navy background, two pages.
Figure 3.Bill — USA: Insurance and payment

05Understanding insurance

Four steps.

Plan — Know the type.1PlanKnow the type.
Network — Check it.2NetworkCheck it.
Bill — Compare with the EOB.3BillCompare with the EOB.
Enrolment — Know the dates.4EnrolmentKnow the dates.
ClarityCosts are known.
ProtectionBilling errors are caught.

06Key points at a glance

TopicIn brief
CardCheck the plan type on your card (HMO, PPO).
NetworkConfirm the doctor and hospital are in network.
EOBCompare the insurer’s explanation with the hospital bill.

07Key terms

Deductible
What you pay before coverage starts.
Coinsurance
Your percentage share.
Out-of-pocket maximum
The yearly cap.
EOB
Explanation of benefits.

08Key points

  • Keep a copy of your card with you.
  • Check that every new centre is in network.
  • Compare bills with the EOB.
  • Ask about charity care.
  • Log every phone call.

09Frequently asked questions

What if I have no insurance?

Look at HealthCare.gov or your state’s Medicaid programme; the hospital financial counsellor can help.

What if I lose my job?

A special enrolment period or COBRA may be possible.

What if a bill is wrong?

Ask for an itemised bill and dispute it.

10Questions for your doctor

Take these questions to your appointment. The ones you save are collected on the “My questions” page and stay on this device only.

  1. What if I have no insurance?

  2. What if I lose my job?

  3. What if a bill is wrong?

My questions

12Sources

  1. HealthCare.gov (U.S. Government). Official website
  2. HealthCare.gov. Coverage for pre-existing conditions
  3. HealthCare.gov. Out-of-pocket maximum/limit
  4. Medicare.gov (U.S. Government). Official website
  5. Centers for Medicare & Medicaid Services (CMS). No Surprises: understand your rights against surprise medical bills
  6. Centers for Medicare & Medicaid Services (CMS). Hospital price transparency
  7. Zentrum für Krebsregisterdaten (Robert Koch-Institut). Krebsdaten (in German)
  8. Deutsche Leukämie- & Lymphom-Hilfe (DLH). Official website (in German)
  9. Kompetenznetz Leukämie. Official website (in German)
  10. Gemeinsamer Bundesausschuss (G-BA). Official website (in German)
Medical disclaimerThis information is for educational purposes only and does not replace medical advice.
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