When immigrating to the United States, it is essential to understand the medical insurance system. It is undeniable that the United States has advanced medical technology; however, in many cases, seeking medical treatment while living in the United States is not a simple matter. If you do not have medical insurance, medical care in the U.S. is not only expensive but also involves cumbersome procedures, and in some cases, you must even schedule an appointment with a doctor in advance. Otherwise, even if you have the money, you may not be able to receive care, which highlights the importance of medical insurance. In the United States, medical insurance consists of both social medical insurance and private medical insurance. So, what are the differences between them? Let us find out below!
Social Medical Insurance
The U.S. Congress passed the Social Security Amendments of 1965, authorizing the government to establish social medical insurance. This primarily refers to "Medicare" (the red and blue card), which is managed by the federal government and aimed at retired seniors and the disabled, and "Medicaid" (also known as the "White Card" in California), which is operated by state governments for low-income residents. Additionally, veterans can apply for Veterans Affairs (VA) health care.
The federal government's Medicare insurance card is often referred to by the Chinese community as the "red and blue card." Medicare consists of two parts: Part B, which covers physician fees, and Part A, which covers hospital expenses. The basic requirements for applying for Medicare are being a U.S. citizen aged 65 or older or a green card holder who has lived in the U.S. for at least 5 years (along with other conditions). Medicare serves retired seniors, individuals with disabilities, and patients with kidney disease requiring long-term dialysis. There is no household income limit for applying for Medicare, but a monthly premium must be paid, and after receiving medical services, there are deductibles and coinsurance.
California's low-income Medicaid insurance card is known as the "White Card" because of its color. Medicaid is largely similar across U.S. states and primarily serves low-income pregnant women, children and adolescents under 19, retirees aged 65 and older, the blind, and seniors requiring nursing home care. Medicaid beneficiaries enjoy free medical services, but their status, age, residency, income, and assets must meet specified criteria. Many retired seniors who came from China sponsored by their children have obtained Medicaid.
Some seniors or disabled individuals may qualify for both Medicare and Medicaid; these patients can enjoy dual coverage. As mentioned above, Medicare patients are required to pay monthly premiums, deductibles, etc., but if a patient also has Medicaid, the state government where the patient resides will cover these costs. Under current circumstances, these individuals do not need to spend a penny of their own money to see a doctor, be hospitalized, or stay in a nursing home (most patients actually have no money). From a physician's perspective, because they have dual insurance and the patient does not need to pay, the patient's motivation to see a doctor is high, and the doctor sees more patients, resulting in higher income. Many doctors prefer patients with both Medicare and Medicaid. Medicare and Medicaid are collectively referred to as "Medi-Medi" and are called the "Gold Card" by many doctors and patients.
Private Medical Insurance
Private medical insurance in the United States is operated by private insurance companies and mainly includes PPO (accounting for 34%) and HMO (accounting for 31%).
PPO stands for Preferred Provider Organization. Its advantage is the freedom to choose doctors. You do not need a referral from a primary-care physician (PCP) and can see a specialist directly. The main issue with PPO is that the insurance premiums are relatively expensive, and patients must pay a portion of the registration fee ($15 to $30 co-payment) when seeking medical care. Each year, before the insurance company pays for medical expenses, the patient must first pay $250 to $1,500; in other words, PPO has a deductible and co-insurance.
Although PPO allows for the freedom to choose doctors, it is still better to have your own primary-care physician. PPO can make it easier for you to find a good primary-care physician, and if necessary, the primary-care physician will help you find a high-level specialist; after all, doctors understand each other much better than outsiders do. Furthermore, regardless of which specialist you see, you should request that the specialist provide a copy of your medical records to your primary-care physician. Most specialists are interested in localized issues, while it is important for your primary-care physician to have a grasp of your overall medical condition.
The main characteristics of HMO (Health Maintenance Organizations) are that insurance premiums are cheaper, the patient's own co-payment is lower, and there is no co-insurance. The less convenient aspect of HMO is that you cannot see a specialist at will; before undergoing many examinations or being referred to a specialist, you need the primary-care physician to apply to the insurance company, and it can only proceed after approval.
The above are some basic characteristics of PPO and HMO. If you are not sure whether your insurance is PPO or HMO, you can check your insurance card. Generally speaking, an HMO insurance card has the name or phone number of your primary-care physician, which is usually a doctor you chose yourself or one designated by the insurance company (see the HMO insurance card below). A PPO insurance card generally does not have the name of a primary-care physician.
From a doctor's perspective, they generally prefer to see PPO patients, which is related to the insurance company's payment method. Like Medicare and Medicaid, PPO is "Fee For Service." A doctor can collect a consultation fee every time they see a PPO patient; the more they see, the more they earn, so the doctor's motivation is high.
HMO is the exact opposite; the insurance company pays the doctor's consultation fee via "Capitation." As long as the patient has selected a primary-care physician, the insurance company pays the primary-care physician a fixed consultation fee regularly, regardless of whether the doctor has seen the patient. For example, if John, a patient with an HMO insurance card, selects Dr. Smith as his primary-care physician, the insurance company pays Dr. Smith $15 every month, regardless of whether Dr. Smith has seen John, totaling $15 X 12 = $180 per year. If John does not go to see a doctor for a whole year, Dr. Smith gets $180 for free; if John sees a doctor twice a year, the doctor's fee per visit is $90 (180/2); if John sees a doctor every month, the fee per visit is only $15 (180/12). In other words, the more times the doctor sees the patient, the lower the fee per visit becomes.
