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Medical Aid/hospitals

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Hi All, can someone please let me know how Medical Aid/Doctors visits, etc work in the US.

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Hi All, can someone please let me know how Medical Aid/Doctors visits, etc work in the US.

There's no simple answer. There are some websites detailing it for new immigrants and you'd probably get better properly detailed info from those. Because most SA immigrants have had private medical aid in SA we are a bit more au fait with the principles than those coming from NHS etc type systems, but a lot is different too. Like SA, the type of plan also determines your excess, copay, coverage, etc. We have no copay for doctor appointments for example but other plans may have $30, etc. Insurance also differs across states. I have to say, while hospital stays cost more our day to day ends up being much cheaper, and our insurance is awesome re info, help etc - puts Discovery to shame.

 

Some things for a saffer to be aware of, there is a difference between "ER" and "urgent care". The latter is often (not always) a good substitute for ER and significantly cheaper. Another is that your medical insurance often dictates the provider you use, not like SA where you just go to whatever hospital etc and claim (well you can here but the cost is significantly bigger). Also, optical and dental are usually addons and not included in the basic plan.

 

I'm not sure how or when the proposed repeal and replacement of Obamacare will affect the current situation.

Edited by SJ27

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To add on to what SJ27 advises:

 

Medical Aid terminology does not exist in the USA - if you ask about that, Americans will be very confused. Use the term Healthcare Insurance or Medical Insurance. As SJ27 notes, Vision and Dental are usually separate - often you will have those through totally separate companies to your main Healthcare insurance.

 

You will encounter terms such as PPO - i.e. a plan will be a PPO plan - which means that you choose one of the Providers (e.g. a Dr) included in the Payer (i.e. your healthcare insurance) network.

 

Plans are either High deductable (more and more popular - i.e. you pay the costs yourself up to the 'high' threshold. This varies - could be $5 000 per year, for example, but then some services, such as health screenings may be 100% covered without you having to pay anything), or a normal plan - which has a much lower deductable. Premiums differ widely, but then so do some of the benefits - e.g. with the high deductable plans you can usually get a HSA (Health Savings Account). This is probably all very confusing until you are living it.

 

Most decent employers will offer one or two plan options.

 

Unlike SA, there are no state/government hospitals for the general public etc - all providers (Dr, Hospital etc) are private. (There are veteran's hospitals, however).

 

Good luck.

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It seems like some people actually know how healthcare works where they are. I was in Massachusetts and could never quite figure it out.... I just nodded when the HR lady explained medical insurance to me. Interestingly, there was a rep from the insurer at work one day and mentioned something that sounded very similar to the medical savings account that discovery introduced here in SA many years ago. When I questioned her about it afterwards, and when she heard I was from SA, she told me that they traveled to SA to learn from the crew at Discovery how it worked etc and then essentially copied it in their organization.

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Another reason to never say the words Medical Aid in the US, is that in a South African accent it sounds very much to Americans like you are saying 'Medicaid', which is a whoooole other kettle of fish and will almost certainly confuse the heck out of the person you are dealing with.

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Thank you so much for all the responses. The one thing I clearly see looking at your posts is that all states really have their own way of doing things. Ok, all of the above makes perfect sense. I was a scared there was the option of Health Insurance vs similar to the NHS in the UK which is really not a good option.

 

Ok, expect 20 000 more questions.

 

Have a super day.

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Having two special needs kids and hitting our high out-of-pocket family limit within the first few months of every year, there are a lot that we had to learn about health insurance over the past 5 years since we arrived in the US.

 

 

Some additional input to what has already been said:

 

1. You get PPO, HMO and EPO plans. PPO is definitely what you want if you're in a situation like ours.

 

2. You lose your job; you lose your health insurance (unless you had private insurance, which is usually ungodly expensive or else, gives you minimal coverage). Most people in the US are insured through their employer's plans, hence you lose your job; you lose your insurance too... Layoffs are pretty easy and quite common in the US, even more so if you're contracting (and usually without notice). Once laid off, you can join COBRA. When on COBRA, expect health providers (Doctors, etc.) to treat or view you with great suspicion - in essence, you bear a cross-hair on your back, because they would know you're out of a job and the risk for default is usually very high. Expect to be made pay in cash in advance for a certain portion of each Dr visit while still on COBRA. COBRA is very expensive and you can only be on it for a max. of 18 months, I think.

3. You could easily face financial ruin (especially if on HMO and EPO plans) if anyone (usually the anesthesiologists who seldom allow themselves to get contracted in) works on you in hospital and if they are not in-network with your health insurance. Even if you insist on only being treated by in-network providers, chances are good that on the day of your op, the hospital couldn't find a particular provider that is in-network (as I said, usually the anesthesiologist) and you're faced with an enormous bill afterwards... Most of the times, upon your appeal, they may agree to make you pay less for it (whatever that amount may be), but there is certainly significant risk there. (Eg. we got a $6,000 bill after confirming that the Lab who did tests on our son was in-network. It turned out that, that was not true and we had to pay... Fortunately, they agreed to squash it to $600. But still... !)

 

4. Make sure you understand the basic concepts common to most insurance plans: Deductible (one person & family), Out-of-pocket limit (one person & family), Co-Insurance, Co-pay and excess, Benefit limits, etc.

 

5. You can ask for and be assigned a case officer at your Health Insurer to assist you if you have many claims to deal with or to assist with motivating and appealing special services to be provided or to be extended beyond their benefit limits. (Probably more relevant in our case than in the average person's)

 

6. Sometimes you may get a bill for a service provided a year or even two later ony... By that time, you may have another Health Insurance already... (we had this several times in the past). Be sure to follow up on bills if you didn't get it.

 

7. Some providers (notably Children's Hospital) is in the bad habit of not sending you a bill for months (up to 6 months in most cases), then on a good day send it to you all at once together with a threatening letter of demand as if you've ignored their previous bills... (we had this a few times in the past as well).

 

8. Never pay a Provider unless they'd submitted their bill to your Health Insurance already. Everything has to go through your Insurance so that they can correctly keep track of your deductible balance, etc. Another reason is that you may have been close to meeting your deductible (or out-of-pocket limit) and another claim ahead of theirs will have reached it, hence you could end up paying the second provider unnecessarily.

 

9. Be sure to log into the Insurer's web site regularly and track all your expenses, in-network providers, your progress towards reaching your limits, etc.

 

10. The IRS allows you to deduct qualified medical expenses that exceed 10% (7.5% if you're over 65) of your adjusted gross income for the year. That includes your insurance premiums, travel costs for medical care, etc. but excludes non-prescription drugs, cosmetics, etc.

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Thanks Reichette. Seems a lot like Discovery in most instances then, besides the late bills. Will have to jack up my admin then...

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