Demystifying the US Health Insurance System
Going through the process of delivering a baby can be an overwhelming and anxiety-inducing one for several of us. The super complex healthcare system in the US does not make it any easier! In this post, we go over some basics of the health insurance system in the US so that you can feel more prepared through your pregnancy and postpartum periods!
The US has public health insurance, which includes Medicare, Medicaid, and Children’s Health Insurance Program, and private health insurance. You can get private health insurance through an employer, the Affordable Care Act marketplace, or directly from an insurance company.
Here are some common terms to be familiar with:
Health plans are programs that provide health benefits through insurance, reimbursement, or otherwise.
Health insurance is a contract that requires your insurer to pay a part of or all of your healthcare costs in exchange for a premium.
Network is the list of facilities or providers (licensed or accredited healthcare professionals) with a contract with your insurer or plan to provide services.
Allowed amount is the maximum amount on which the insurance payment is based for a covered healthcare service. If the provider changes more than the allowed amount, you may have to pay the difference and this is called balance billing.
Premium is the amount that you, your employer, or both should regularly pay to your health insurance or plan.
Deductible is the amount you pay for healthcare services before your insurance or plan begins to pay
Co-insurance is your percent share of the costs of a covered healthcare service. You pay co-insurance plus any deductible you owe
Co-payment is a fixed amount you pay when receiving a covered healthcare service.
In general, in-network co-payments and co-insurance are lower than out-of-network providers. So, it is best to use in-network facilities and providers whenever possible.
Out-of-pocket limit is the maximum you pay during the policy period (generally one year) before the health insurance or plan pays 100% of the allowed amount. This limit never includes your premiums, balance billing payments, or anything that your insurance does not cover. Additionally, some health insurance plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments, or other expenses towards this limit.
The health insurance system is complicated in the US. It's best to understand the specificities of your plan early in your pregnancy to avoid surprises later on. It is also best to understand if the providers you may need during your postpartum period, such as mental health therapists, pelvic floor therapists, lactation consultants, etc., are in-network for you. Getting these details sorted early can go a long way in making the postpartum experience smoother and less stressful.
