Are US residents required to have health insurance?

The US health insurance system is quite complex for foreigners to learn. We already wrote a general article about medicine in the United States.

In this material, we will consider the health insurance system in the United States: what is its cost, what are the ways to apply for it.

To begin with, it should be noted that the health care system in the United States is the most expensive in the world. For each inhabitant of the country, the government spends about $15,000 a year, and the annual turnover of the amount to pay for medical programs costs the state $3 trillion. Despite this, a concept similar to the Russian CHI is not provided here. The state pays health insurance only for poor citizens, the disabled, the elderly and other needy.

Main state support programs:

Medicare is the US public health insurance program for people 65 and older. This program is also designed for residents under 65 who have a disability or a particularly serious illness, such as kidney failure. The program does not cover all medical care, but helps pay for most medical services.

Medicaid is a federal program that helps pay for health care for low-income US citizens. This program provides benefits not normally covered by Medicare, including home care services.

The Children’s Health Insurance Program (CHIP) is a program that provides assistance to families with children. The program targets uninsured children in low-income families where incomes are modest but higher than Medicaid requirements.

Are US residents required to have health insurance?

Yes, every American is required to have health insurance. Otherwise, you will have to pay all the costs of treatment yourself, and medical services in the United States are very expensive, although in some cases it may be more profitable to consult a doctor directly.  

Also, a person without insurance will have to pay a fine of $ 1,000 for evading compulsory insurance. Rarely ill people prefer to pay a fine, as it turns out to be more profitable for them than buying insurance.

How can I get health insurance?

Here are the main ways to get health insurance:

  • The needy segments of the population, the disabled and the unemployed are fully or partially paid for by the state.
  • If the family income is low and the employer does not pay for insurance, then you need to arrange it yourself. If the family falls under the requirements of the state health insurance program, then part of the insurance premiums will be compensated by the state.
  • When applying for a job, you need to find out whether the employer will pay for your health insurance, in part or in full. This is a very common practice in the US. Through the employer, you can get profitable insurance not only for yourself, but also for your family.
  • Entrepreneurs and those for whom the employer does not pay insurance are required to arrange it at their own expense.
  • Persons under 26 can take out health insurance through their parents.

Dental health insurance and vision insurance are issued and paid separately.

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Is treatment free of charge if you have health insurance?

Unfortunately no. Health insurance in the United States in most cases reimburses only a part of the costs, however, given the cost of services in the United States, it will often be more profitable than paying for treatment entirely out of your own pocket. The amount you have to pay yourself depends on the insurance plan and the service itself. For example, the annual examination of a therapist is covered by insurance by 100%.

How does the insurance payment system work?

When contacting the clinic, you must present an insurance policy. Based on the format of your health insurance, you will need to pay one or another amount for medical services.

What are the terms of health insurance?

  • Deductible – out-of-pocket expenses for medical care, before the start of insurance coverage;
  • Co-pay is a fixed amount that must be paid independently for any medical service, the rest of the amount is covered by the insurance company;
  • Co-insurance – a certain percentage is paid independently, the rest of the costs are covered by the insurance company;
  • Out-of-pocket maximum – a certain maximum cost per year, which is fully compensated by the insurance company.

Where to get insurance?

The sale of insurance policies is strictly controlled by the state. Therefore, at the moment, the only platform for purchasing a medical policy of any insurance company is Here you can compare formats and types of insurance and choose the most profitable option. The law also provides for the period for purchasing medical insurance – from November 15 to February 15. But if a person’s social situation has changed, for example, he got a different job / he has a wife / husband / children, then insurance is issued at any time of the year.

What types and plans of insurance are there?

The two main types of health insurance policies are:

  • Health maintenance organizations (HMO) is a budget insurance option that includes a specific network of medical clinics. This insurance policy does not apply to private practice doctors.
  • Preferred provider organizations (PPO) is a more expensive insurance option. With her, the choice of doctor and clinic is freer than with HMO. If the insurance company has an agreement with the selected clinic, then you will have to pay quite a bit; if there is no contract, the amount of independent part of the payment will be already higher. But the choice of clinics for this type of insurance is much larger than for HMO.

After choosing the type of insurance policy, you need to choose a plan that determines the self-payments and compensation of the insurance company.

Basic insurance plans:

  • Platinum – the insurance company pays 90% of the costs of medical services, respectively, the monthly premiums for this policy are quite high.
  • Gold – compensation from the insurance company – 80% of the costs.
  • Silver – 70% of the costs are paid by the insurance company.
  • Bronze – compensation is 60%. This plan is in high demand as it is relatively inexpensive.
  • Minimal is the most budget-friendly plan that only covers basic medical services. Only persons under 30 years of age and those who for any reason have lost their current insurance can issue it.

How much does health insurance cost?

The cost of insurance consists of the type and tariff plan chosen. The average cost of a medical policy for an adult is $250 – $400 per month. For a family, monthly premiums for insurance will be from $1,000.


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