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How to Get Health insurance and Understand the Healthcare System

When it comes to staying healthy, the best defense is a good offense. By maintaining a healthy lifestyle, you can prevent health complications down the road.

Of course, we all have to go to the doctor at some point – whether for a checkup, preventive exams, or specialized care. If you’re unsure about how to get health insurance in the U.S., check out our guide to health plans below. By understanding your health insurance options, you can get access to the care you need and stay as healthy as possible.

Trust the health care system

The health care system in the U.S. consists of reliable medical professionals and organizations. Here we will go over the key health professionals and facilities available and explain some of the services they provide.

Physicians and healthcare professionals

These professionals have a degree in medicine and several years of formal education and training. In order to practice medicine in the U.S., physicians and health professionals must be licensed and certified by passing standardized exams.

Community Health Workers

Community health workers are Spanish-speaking members of the Latino community that are trained by local hospitals, clinics, and physicians to perform the following tasks:

1. Educate the Latino population on how to access healthcare and other related issues.

2. Lead health programs in their communities.

3. Help the Latino community identify and enroll in government-sponsored insurance programs.

Hospitals

Hospitals offer healthcare services to all communities and people, regardless of their ethnic, religious, or economic background, their ability to pay, or their immigration status.

You can get healthcare regardless of your immigration status

Pharmacies

At pharmacies, you can fill your prescription (Rx) or buy over-the-counter (OTC) medications. All pharmacists go through rigorous education and training before getting their license, which means that they’re well-prepared to give you advice about your health.

Community clinics

Community clinics provide healthcare to the uninsured and underinsured in low-income communities. They offer the same high-quality care and standards as any hospital.

“Ventanillas de Salud” program

The Mexican Consulate runs a program called “Ventanilla de Salud.” With this program, you can get healthcare information as well as advice on getting prompt medical care, regardless of your immigration status.

Visit your nearest Ventanilla de Salud

Beware of individuals that claim to be "healers" and "herbalists". These workers aren’t licensed by the U.S. government; their treatments may be ineffective and even dangerous for your health.

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What’s health insurance?

Health insurance, also known as a health plan, is a policy that provides partial or full coverage for medical expenses obtained as a result of an illness or injury. In other words, insurance helps you pay for the care you receive at a hospital, clinic, or specialist.

Keep in mind: Unlike other countries, the United States doesn’t have universal health coverage. If you don’t have health insurance, you’ll have to pay for medical expenses out-of-pocket. This could cost you thousands of dollars in the event of a serious illness!

What’s NOT health insurance?

Nowadays, there are medical services available to help you get low-cost care. While these services aren’t considered health insurance, they can make it easier for you and your family to see doctors at affordable rates.

One popular example of this type of service is telemedicine. As its name suggests, telemedicine provides medical services remotely, either by phone or video call. We’re proud to offer telemedicine services through our PODERsalud program.

Learn more about telemedicine

Keep in mind: Telemedicine services can help diagnose general health conditions, such as allergies, colds, fever, sore throat, etc.

The importance of health insurance

Knowing how to get health insurance will make it easier for you to receive medical treatment. At the same time, insurance can benefit you financially, since it will cover part or all of your medical expenses.

Another key benefit of health insurance is that you have greater flexibility. Health insurance gives you access to more options for treatments and preventative programs in case you’re diagnosed with a chronic or prolonged illness.

How health insurance covers you and your family

Health insurance can give you peace of mind. With it, you’ll be prepared for the unexpected and be able to help your family:

  1. Pay for healthcare expenses;
  2. Get access to higher quality medical care;
  3. Negotiate lower-cost medical services with providers;
  4. Get your questions answered through phone support;
  5. Access medical resources to advocate for both you and your family.

Keep in mind: Look for insurance companies that offer customer service in Spanish, either on the phone (through an 800 number) or a Spanish-language website. This way, you'll always have access to someone who speaks your language.

Three types of health insurance

As you learn how to get health insurance, here are the three main types you should consider:

  • Individual and family plans;
  • Group plans;
  • Government-sponsored plans.

Our guide will help you understand the options available to you so that you can make the best possible decision when choosing a health insurance plan.

Individual and family health insurance plans

These plans are sold directly to the individual. They’re ideal for those who don’t qualify for government-sponsored insurance or whose employer doesn’t offer health insurance.

Group health insurance plans

Group health insurance may be offered by companies, organizations, professional associations, religious organizations, or other groups. The employer or organization pays part or all of the health insurance costs.

Government health insurance plans

You may be eligible for government-sponsored plans as long as you meet the requirements, which are typically defined by age, income, or disability standards. Medicare and Medi-Cal are examples of health care plans offered by the government.

Keep in mind: In the United States, the only dependents covered by family health insurance plans are your spouse and any children under the age of 18 (or up to age 24 if they’re enrolled in school). Other members of your family who live with you, or who you support aren’t considered dependents.

Key features of health insurance plans

Whether your plan is individual, family, group, or government-sponsored, health insurance generally falls into two groups: Managed Care and Fee-for-Service. As you learn how to get health insurance, it’s important to know the features of these two types of health plans.

Managed Care Plans

Manage Care includes HMO, PPO, and POS plans (see the details below). Generally speaking, the insurance company manages your plan and provides a network of doctors you can go to for health care and services.

With this type of insurance, you may need preapprovals from your insurance provider to get coverage for certain services, including visits to specialists, medical exams, or surgeries.

Health Maintenance Organization (HMO)

Under this plan, you must use the health services detailed within the plan's defined network. In addition, you must choose a Primary Care Physician (PCP), who will provide, coordinate and authorize all aspects of your family's health care.

If you see a specialist without the consent of your Primary Care Physician, or if you go to an out-of-network health care provider, you’ll be responsible for all applicable costs.

While HMOs limit your ability to choose your health providers, these plans typically offer the most benefits for the lowest cost.

Preferred Provider Organization (PPO)

Like HMOs, PPOs also make use of a network of providers (also called "preferred providers”). However, this network is usually much larger than an HMO’s, so you have more options to choose from. Though you may be required to elect a Primary Care Physician, you don’t need a referral to see a specialist or another healthcare provider within the network.

The flexibility of this plan also lets you use out-of-network health care providers, but the rates are still generally higher.

Point of Service (POS)

A POS plan also uses a network of contracted health providers but offers a mix of HMO and PPO services. Like an HMO plan, you must select a Primary Care Physician who will help you get referrals and keep costs down when you need to see specialists.

Nonetheless, like a PPO plan, you can select other providers in or out-of-network, as well as with or without referrals – though these health services may cost more. Because they offer greater flexibility in choosing providers, POS plans are usually more expensive.

Fee-for-Service

Compared to the plans mentioned above, this type of health plan gives you the most freedom to choose a doctor, hospital, or other healthcare provider. Typically, the insured individual is charged an annual deductible, which means that coverage doesn’t kick in until that amount has been reached. Only then, the health plan will start to partially cover expenses for medical services.

How to select the right health insurance

Now that you know how to get health insurance, it’s time to select a plan. Choosing the right plan for you and your family is especially important if your employer doesn’t offer group health insurance, or if the insurance offered is very limited. Remember that you always have the option to purchase individual or family health insurance.

We recommend comparing your options carefully, as insurance coverage and costs vary from company to company.

Tips for purchasing individual or family health insurance

Understanding how to get health insurance can be challenging. However, it’s easier to select a health plan if you know what to ask. First, decide what’s most important to you and your family, and then follow the tips below to help you decide.

1. Analyze the health plan’s benefits

Some plans may be perfect for some, but not for you and your family. For every plan you’re considering, check what benefits it offers, including:

  • Checkups and preventive care (such as immunizations for children);
  • Hospitalization and urgent medical care;
  • Prescription and over-the-counter medications;
  • Long-term health care for chronic or long-term illnesses;
  • Physical therapy and other rehabilitative health care;
  • Chiropractic or alternative treatments, such as acupuncture;
  • Dental and vision insurance coverage. 

2. Find out how much the health services will cost

No health insurance plan will cover all your expenses, but you should find out:

  • What deductibles must you pay before your health insurance kicks in?
  • Once the deductible is paid, how much of your health care expenses does the plan cover?
  • Do you have to make copayments for certain services, such as checkups?
  • If you see doctors outside of the plan's network, how much is covered by the plan?
  • Are there any limitations on how much you have to pay in the event of a serious illness?
  • Is there a limit on how much the plan will cover per year or lifetime?

3. Read the plan details carefully

You must compare plans carefully before purchasing one.

  • Keep in mind that policies vary widely in terms of benefits and costs. Contact different insurance companies to make sure these terms are right for you and your family.
  • Make sure your individual insurance policy protects you from major medical expenses. Read the policy details carefully to avoid unpleasant surprises when you become ill or are hospitalized. If you have questions, don't hesitate to contact the insurance company.
  • Check if the policy contains a "reconsideration clause," which gives you at least 10 days to review your policy. If you decide it isn’t right for you, you can cancel and get a refund of your initial payment.
  • Beware of insurance policies that offer coverage for only one illness, such as cancer.

Before purchasing any insurance policy, be sure you understand the plan details, including what it does and doesn’t cover.

Keep in mind: Did you know some health insurance plans offer coverage for your family members both in the United States and Mexico?

How to make the most of your health insurance

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To get the best medical care possible, you need to understand how your health plan works, including what your rights are and how to file a complaint. If you aren’t satisfied with your treatment, you should speak directly with your doctor and your insurance representative.

Voice your opinions

  • Take notes during any phone calls or appointments.
  • Ask for the name of the person you’re speaking with and write it down.
  • Have someone go with you to appointments for extra support.
  • If someone says he/she can’t provide the care you’re requesting, ask for the reason in writing.
  • If someone shows no interest in helping you, ask to speak to the supervisor.
  • If someone gives you conflicting information about your eligibility for health services, demand to speak to their supervisor.
  • Be persistent. You may need to make several calls to get the services you need. Keep a record of the dates you made these calls and the names of the people you spoke with.

Remember that you have rights

  • To be treated with courtesy and respect;
  • To receive high-quality and prompt medical treatment;
  • To get an appointment when you need it;
  • To receive medical care from qualified health professionals;
  • To choose a doctor you trust;
  • To request a second opinion;
  • To choose or refuse treatment. 

Keep in mind: In California, HMOs are regulated by the government. If your insurance company doesn’t address your concerns about your policy and consequently puts your health at risk, you can file a formal complaint by calling the state’s 24-hour toll-free number 888-466-2219.

How to live a healthy lifestyle 

Keeping up healthy habits can help your family now and in the future. It’s especially important to encourage healthy habits during childhood. After all, the habits we make as kids can have a lasting impact on our health as adults. Consider incorporating the following habits into your family’s routine.

Key habits for healthy living

Nutrition is key to healthy living. It’s vital to eat a balanced diet and avoid foods high in fat, salt, and sugar. In addition, you should limit or completely avoid (if possible) consuming alcohol and tobacco.

However, when you eat meals can be just as important as what you eat. For example, breakfast is the most important meal of the day because it provides the energy you need to be productive. This is true for you and your kids! Experts say that kids perform better in school if they eat a healthy breakfast. Generally speaking, a healthy breakfast consists of protein (such as eggs, milk, or cheese) and nutritious carbohydrates (such as fruit, juice, cereal, or whole-grain bread).

In addition to a balanced diet, a key ingredient to healthy living is exercise. You and your family should exercise for at least 30 minutes a day, three times a week. Examples of physical activities include walking, running, biking and swimming. These cardiovascular exercises can help reduce harmful cholesterol levels while burning excess body fat.

Keep in mind: You may benefit from seeing a doctor before starting a new diet or exercise plan.

Tips for healthy living

  1. Keeping up your health is a must. Preventive health care should be a top priority so that you can take action before illness strikes!
  2. If you understand how your health services work, you’ll be better prepared for the unexpected. For example, you should clearly understand how to get health insurance, types of health plans and providers, and how to get treatment and medications.
  3. Healthy living can be uplifting. Taking care of your health can allow you to enjoy life to the fullest!
  4. By prioritizing your health care and using the health services available to you, you can prevent cardiovascular disease, diabetes, cancer, and even depression.

Keep in mind: Scheduling a checkup with your doctor can be a good resource before starting a new diet or exercise plan. 

5 health risks you can prevent with an annual checkup

Glossary

Co-insurance

Co-insurance is how much you have to pay for health care in a Fee-for-Service plan after you have paid the deductible. The amount you must pay is typically expressed as a percentage. For example, if the health insurance company pays 80 percent of the claim, you must pay the remaining 20 percent.

Copayment

Copayments are the fees you must pay every time you receive medical services (for example, $5 for a doctor's visit). The health insurance company will pay the rest.

Covered Expenses

Most insurance plans don’t cover expenses for all health services. (For example, some pay for prescription drugs, while others don’t.) Covered expenses are medical procedures that the insurance company agrees to pay for in part or in full. You can find a list of covered expenses in your insurance policy.

Deductible

The deductible is the amount of money you must pay annually to cover your healthcare expenses before your health insurance policy kicks in.

HMO - Health Maintenance Organization

With this type of prepaid plan, you pay a monthly premium; the HMO covers your doctor visits, hospitalizations, urgent care, surgeries, checkups, lab tests, X-rays, and therapies. To get coverage, you must receive treatment from doctors and hospitals within the HMO’s network.

Managed Care

This type of health plan manages the costs, usage, and quality of the healthcare system. For example, HMOs and PPOs are considered managed care plans.

Network

A network consists of a group of physicians, hospitals, specialists and other health care providers contracted by an insurance company to offer services at a discounted rate.

OOPM - Out-of-Pocket Maximum

This is the amount you have to pay for deductibles and coinsurance. The insurance company establishes a "Maximum" that you must pay annually for your medical expenses – not including premium payments.

POS - Point of Service

This type of plan combines the features of HMOs and PPOs. Like an HMO, you can see doctors and get referrals in-network for better coverage of your medical expenses. However, you can choose to see other doctors with or without referrals, though at a higher cost.

PPO - Preferred Provider Organization

With this type of plan, an insurance company’s network of health care providers has been contracted to provide care at a discounted rate. A PPO plan will give you greater flexibility in choosing doctors and seeing specialists in-network. While you may be able to see out-of-network providers, it will cost more.

Premium

This is the amount of money you or your employer pay (usually monthly or quarterly) in exchange for health insurance coverage.

Primary Care Physician

A Primary Care Physician is typically your first point-of-contact to receive medical care. Some women choose their gynecologist as their primary care physician. Overall, a Primary Care Physician keeps medical records of your care and refers you to specialists as needed.

Provider

Any person (physician) or institution (hospital/clinic) providing medical care.

Referral

A formal referral, usually provided by a Primary Care Physician, is often required for the insured individual to receive health services from a specialist or another physician – especially under an HMO plan. Referrals typically make use of the insurance company's in-network partners.

Telemedicine

This remote health care service is available 24/7 and can be accessed by phone or video call.