Hello Johnie,
It has been a while since I posted. There is a reason for that, which I will discuss in my next post.
For now, read on to see how to access healthcare as a new immigrant.
Healthcare and access to healthcare are vital for a new immigrant for a variety of reasons. If you are young and relatively healthy, this may not be top of your mind, but this is something you need to pay attention to. Health care in the United States, for better or worse, is very complicated. Understanding how to access health care as a new immigrant while you are settling down can help you avoid costly mistakes. Health care in this country is expensive. In fact, healthcare debt is a burden for many people living here in the United States. As many as 41% of Americans carry debt ranging from $500 to > $10,000.
In this blog post, I will provide an overview of the healthcare system in the United States, options for coverage, available resources, potential barriers, and how to access healthcare as a new immigrant.
The Basics of Healthcare in the United States
The US has a very complex healthcare system with systems within systems and private and public healthcare providers. It has systems within systems in the sense that some healthcare and healthcare coverage is provided solely by the government to specific individuals, like in the Veterans’ Administration healthcare system. In contrast, other systems have health services provided by private facilities, but the government provides access (insurance), and finally, another system in which private facilities provide both access and services. Still, another option is to have care provided by private companies but subsidized by the government.
Facilities where you can access care include clinics, urgent care centers, hospitals, and emergency rooms. You are probably familiar with most of these types of facilities, but Urgent Care Centers you may not be familiar with. Urgent Care centers, also known as Express Care centers, are centers where you can go for urgent but not emergent needs. Think cuts, falls, broken bones, medication refills if needed, etc. They are equipped to handle needs that may not necessarily be covered by your doctor’s office, plus some covered by your doctor’s office but that do not require an emergency room visit.
Another more popular way to access care is through direct care clinics, typically primary care, but also becoming increasingly popular for specialty care. Direct care clinics are not clinics where you pay a membership fee, usually monthly, to access care. You are sometimes guaranteed 24/7 access to your doctors, and your monthly fee includes the majority of care you will need, including procedures, consultations, and sometimes laboratory tests and medications. If laboratory tests and medications are not included in your membership fee, then they are usually available at a nominal fee. Your appointments with your doctor are usually longer because the doctor will cap membership after a certain number of patients. These may be a great option for you if you have no insurance coverage but afford a monthly fee for access, especially for primary care.
Another way to access care is virtual visits- either a video visit or a telephone call with your doctor. This method has become more popular since the pandemic and is now likely here to stay.
The individuals who will provide care include physicians, nurse practitioners, physician assistants, and, less commonly, nurse anesthetists.
Healthcare Practitioners
A physician is an individual who has completed medical school and subsequently completed specialty training in the specialty of choice. They have the most years of training out of all individuals who provide care; they are doctors in the traditional sense of the word.
Nurse Practitioners are individuals who went to nursing school and obtained advanced degrees in nursing, allowing them to practice as a physician extender. In some states, they are able to practice independently of physicians.
Physician Assistants go to physician assistant school and typically practice as a physician extender under the supervision of a physician.
Nurse Anesthetists are individuals who go to nursing schools, have advanced degrees, and practice as anesthetists for surgeries. You will likely receive care from nurse anesthetists, hopefully infrequently.
Where and who you can access care from is primarily determined by your healthcare insurance coverage, which I will cover next.
Health Insurance Options for New Immigrants
There are three main options for health insurance available to new immigrants who are not students in the US and one additional option for students, which I will discuss briefly. These options are employer-sponsored health insurance plans, Medicaid health insurance plans, Affordable Care Act Plans, and, last but not least, student health insurance plans. I will cover all of these plans in detail below.
Before applying for any of these options, you need to make sure you have a social security number; you will need this to apply for insurance. If you have not applied for your social security number yet, read this blog post on the steps to take to apply for your social security number. I go over how to apply step by step and in detail.
Key Terms
There are some key terms you should be familiar with when it comes to health insurance.
Cost Sharing
The cost of healthcare is split between you, the insured, and the insurance company. Somewhat self-explanatory. This occurs in different ways- a deductible, a co-pay, and co-insurance. All of these costs reset at the beginning of each calendar year. For example, if your deductible is $500 and you hit your deductible mid-year of 2023, for the rest of the calendar year in 2023, the $500 will count towards your other healthcare costs. On January 1st, 2024, your deductible is reset to 4) and you have to spend $500 to hit your deductible for the new year. I hope you understand what I mean; if not, drop a comment below.
Deductible
This is the amount you typically have to pay before your insurance company will start to pay for your health care bills. The amount varies depending on the insurance plan.
Co-pay
These are the amounts your insurance company requires you to pay upfront for each visit to doctors, the emergency room, urgent care, etc. This amount counts towards your deductible.
Co-Insurance
This is the amount, usually a percentage, you are required to pay for health care services once you have hit your deductible but not yet hit your out-of-pocket maximum.
Out-of-Pocket Maximum
This is the maximum amount of dollars you can spend on your healthcare in a calendar year. After you hit this amount, all of your care should be covered by your health insurance plan, provided you stay in-network.
In-Network
Your insurance plan often will contract with certain hospitals, doctors, clinics, etc., for negotiated rates and discounts on health care. These facilities and professionals will be ‘in-network’ for you, i.e., if you go to these facilities or professionals, your care will be cheaper and covered by your insurance plan. Some insurance companies will offer Tiers/levels with increasing costs depending on the tiers; Tier/Level 1 will be cheapest for you, Tier/Level 2 will be slightly more expensive, etc. Be careful to stay in-network for your insurance plan because sometimes, your insurance plan may not cover expenses you incur at out-of-network facilities/doctors.
Out-of-Network
These are facilities and professionals who are not contracted with your insurance plan. If you choose to obtain care at one of these facilities or from one of these professionals, your insurance may not cover your expenses, and you may be stuck with a bill. The caveat is emergency situations can be the exception.
Now, let’s discuss the options for coverage, AKA insurance.
Employer-Sponsored Health Insurance
This is one of the most popular forms of insurance coverage in the US, even for nonimmigrants. Employer-sponsored plans are estimated to cover about 54% of Americans. Many employers offer health insurance benefits to their employees, and this is a fantastic option if you have this option available to you. It often provides comprehensive coverage, including doctor visits, hospital stays, medications, physical therapy visits, and preventive care. Some plans will even offer coverage for items like acupuncture, massage therapy, and more. When you start a new job, be sure to inquire about the health insurance options available to you and how to enroll.
This is very important- your period to enroll in this option is usually limited and varies depending on your employer. Some employers will offer a 30-day period, others a little longer. Be sure to pay attention to this detail so you do not miss out on enrolling in health insurance, which is one of the benefits you are entitled to as an employee.
Medicaid
Medicaid is government-funded health insurance program for low-income individuals and families. You will have to meet certain income requirements to qualify. As an immigrant, you also have to be a legal permanent resident in order to apply for this; otherwise, you may be subject to the ‘public charge’ rule, which will then prevent you from becoming a legal permanent president of the United States. You do not want this to happen to you.
Medicaid is a federal program administered by each state. Thus, rules for every state differ, and your ability to obtain medical insurance depends on which state you live in. Be sure to check the state informational website specific to yours to see what the eligibility requirements are for you.
Along with Medicaid, if you have children, they may be eligible for obtaining coverage under the Children’s Health Insurance Program (CHIP). Your household has to meet certain income requirements (below a certain threshold), and obtaining health insurance through CHIP is not subject to the public charge rule.
Important note about ‘public charge’. In 2021, the Biden administration made changes to the public charge rule, removing the application and use of general Medicaid, CHIP, and other general health coverage from the public charge test. This means you can apply for these benefits without fear of becoming ineligible for permanent residency status. HOWEVER, special note about Medicaid: If you use your Medicaid insurance for long-term institutional care, for example, nursing home care or mental health admissions long term, you will become ineligible. Take special note of this. These rules are also subject to change, so make sure you check for the most recent rules and speak with an immigration lawyer if needed.
The Affordable Care Act Marketplace
The Affordable Care Act (ACA) or ‘Obamacare’ Marketplace is a website where individuals and families can shop for and purchase health insurance plans. To be eligible, you have to live in the United States, be a citizen, permanent resident, or be a US person, not be in jail, and meet certain income requirements.
You will need to set up an account prior to purchasing a plan on the marketplace.
Other Important Information
Types of Plans
Since the advent of reducing healthcare costs for insurance companies and increasing costs for the insured, you will typically have two options available to you- a traditional healthcare insurance plan and a high deductible healthcare plan.
A traditional healthcare plan will have a lower cost deductible, usually a little more expensive than the alternative when the costs are taken out of your paycheck, and you may have a flexible spending account available to you. A flexible spending account is an account you can choose to make pre-tax deductions into for use for healthcare costs for you or your dependents in the calendar year. You have to spend the money deposited into that account in the calendar year, or it is forfeit.
A high deductible plan will have a higher deductible, usually at least two times higher than a traditional plan. However, you pay less when the cost of this plan is taken out of your paycheck. You will likely have access to a Health Savings Account, which is very exciting because you can contribute money to this account annually (there is an IRS limit), and you do not have to spend it in the calendar year. In fact, you can and should invest the money to let it grow. For people who choose a high deductible plan, this can be an additional stealth retirement account (more to come on this). To review options for retirement accounts in the US, see this blog post.
How do you choose between both? You have to consider your unique situation. If you are relatively healthy and on no prescription medications, the high deductible plan can be a good option for you, as it gives you access to the HSA. If you have a lot of chronic conditions and need a lot of care, this does not automatically exclude you from the high deductible plan, but if I were you, I would lean towards the traditional plan. Again, consider your unique position.
This is a good point to mention that at the time of publishing this blog post, all preventive care is covered with no cost-sharing due to legal requirements. Therefore, an annual physical, accompanying lab tests, colon cancer screening, mammogram, pap test, etc., is covered at no cost to you regardless of whatever insurance coverage you have, including insurance plans not provided by your employer.
Open Enrollment
For any plan you enroll in, once you have made your elections, these usually last the whole year; however, during ‘open enrollment’ period or if you have a significant event during the calendar year (you get married, have a baby, adopt or go through a divorce), you may switch plans if you choose to.
That’s it!
It is a dense but important topic, and I hope you are walking away from this post with the knowledge you need to obtain health insurance and obtain care in the United States. Make sure you stay informed with up-to-date knowledge. Till next time…
Your comrade,
Johnie