Healthcare and Healthcare Insurance Basics

Healthcare system is very complex in the United States. Even people who live here all their lives sometimes have trouble navigating it. In order to understand how healthcare and healthcare insurance work, you need to know some basics.

First of all, there are inpatient and outpatient healthcare services. Inpatient care is provided in hospitals, mental health institutions and nursing homes. Usually for inpatient care you have to stay in these institutions at least overnight and up to several weeks.

You do not have to stay overnight for outpatient care. Usually, individual doctor’s offices, clinics and hospitals all provide inpatient care.

Hospitals, the main providers of healthcare, can be public (run by federal, state or local government) or private (nonprofit and for-profit). Veterans’ hospitals are usually run by the federal government, psychiatric institutions – by state governments, and public hospitals – by city government (e.g. in New York City: Bellevue Hospital Center, Coney Island Hospital, Harlem Hospital Center, Elmhurst Hospital Center and some other). Other hospitals are either religious nonprofit institutions (e.g. New York-Presbyterian Health Care System hospitals), non-religious nonprofit hospitals (e.g. Montefiore Medical Center, Maimonides Medical Center, Lenox Hill Hospital and many others) or for-profit hospitals and clinics (there are no for-profit hospitals in New York).

Outpatient care is mostly provided by private doctors that provide primary care (e.g. family doctors or primary physicians) or specialized care (e.g. neurologists, eye doctors and cardiologists). Doctors either work alone or in small groups.

Health Insurance

In order to receive good and consistent care a person needs a health insurance policy.

The insurance company usually charges a monthly fee, called the premium. When you receive health care services, the insurance company will pay your doctor, clinic or hospital on your behalf. However, you still are required to pay for some of the cost. The deductible is a fixed-dollar annual amount of health care costs that you must pay entirely out of pocket. For example, if the deductible on your insurance is $500, the first $500 in medical costs each year is paid by you. “…..Costs beyond $500, the insurance company may pay completely or require a copayment or coinsurance. A co-payment (or “co-pay”) is a fixed-dollar amount that you must pay for certain services. For example, the policy might say that the beneficiary pays $15 out of pocket for each primary care visit and $25 for each specialist visit, while the insurance company pays the rest of the bill. Coinsurance is similar to co-payment, but it’s a percentage of the bill rather than a fixed amount. For example, the beneficiary might pay 20% of the cost of a primary care visit and 25% of the cost of a specialist visit, and the insurance company pays the rest” (quoted from Moore, Nathan; Askin, Elisabeth (2012-06-01). The Health Care Handbook).

Most people in the United States get their health insurance from their employers as part of the work benefits package. Usually, workers pay part of the health insurance premium to employer, and employer adds the rest of the premium and pays all to the insurance company. How much each health insurance plan or policy cost depends on the type of the health insurance company. Because healthcare services are very expensive, health insurance plans tries to keep the expenses low by trying to manage your care by setting up various rules on how you can use healthcare services.

If your employer does not provide a health insurance, or if you are unemployed, it becomes very difficult to buy your own health insurance. It’s just too expensive. There are over 30 million Americans who do not have any health insurance.

If your household income is really low (see a table of maximum incomes below), you can qualify for free or low-cost public insurance like Medicaid, Family Health Plus or Child Health Plus (sponsored by federal and local government together, paid for by general tax revenue). You also have  to be a legal permanent resident or a citizen to request a public healthcare insurance. To find if you are eligible, you can visit Medicaid offices at public hospitals (Bellevue, Coney Island or Elmhurst) or contact community providers Affinity Health Plans or Amerigroup.

More about various healthcare insurance options here and here.

Some answers about Medicaid below (from New York State Department of Health website):

How do I know if my income and resources qualify me for Medicaid?

The chart below shows how much income you can receive in a month and the amount of resources (if applicable) you can retain and still qualify for Medicaid. The income and resource (if applicable) levels depend on the number of your family members who live with you.

2013 Income & Resource Levels*

Medicaid Standard for Singles
People, Couples without
Children & Low Income
Families

Net Income for Families; and Individuals who
are Blind, Disabled or Age 65+

Resource Level
(Individuals who are Blind, Disabled or Age 65+ ONLY)

Annual

Monthly

Annual

Monthly

1 $8,994 $750 $9,600 $800 $14,400
2 $11,228 $936 $14,100 $1,175 $21,150
3 $13,360 $1,114 $16,215 $1,352 $24,323
4 $15,512 $1,293 $18,330 $1,528 $27,495
5 $17,737 $1,479 $20,445 $1,704 $30,668
6 $19,364 $1,614 $22,560 $1,880 $33,840
7 $21,078 $1,757 $24,675 $2,057 $37,013
8 $23,278 $1,940 $26,790 $2,233 $40,185
9 $24,538 $2,045 $28,905 $2,409 $43,358
10 $25,800 $2,150 $31,020 $2,585 $46,530
For each additional person, add: $1,262 $106 $2,115 $177 $3,173

*Effective January 1, 2013

For more details, use the ACCESS NY Public Health Insurance Eligibility Screening Tool to see which public health insurance programs you and your family may be eligible for.

Income and Resource Levels are subject to yearly adjustments.

You may also own a home, a car, and personal property and still be eligible. The income and resources (if applicable) of legally responsible relatives in the household will also be counted.

Can I be eligible for Medicaid even if I make more money than the chart shows?

Yes, some people can. Pregnant women, children, disabled persons, and others may be eligible for Medicaid if their income is above these levels and they have medical bills. Ask your Medicaid worker if you fit into one of these groups.

Click here for more information on the Medicaid Excess Income program.

Individuals who are certified blind, certified disabled, or age 65 or older who have more resources may also be eligible. Ask your Medicaid worker if this applies to you.

If an adult has too much income and/or resources and is not eligible for Medicaid, that person may be eligible for:

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2 Comments on “Healthcare and Healthcare Insurance Basics”

  1. […] Medicaid is intended for low-income individuals and families. Read more about health insurance on our previous post […]

  2. […] Medicaid is intended for low-income individuals and families. Read more about health insurance on our previous post […]


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