Health insurance: How does it work in the US?

If your employer doesn’t supply you with health insurance, you’ll have to set it up on your own. There are two types of health insurance in America: PPO and HMO.

PPO (Preferred Provider Organization)

The PPO is a managed care organization of medical doctors, hospitals and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer’s or administrator’s clients.

Meaning you will only be able to use the doctors which are partnered with the assurer. If this is not the case, the assurance will not reimbursance your medical bills.

HMO (Health Maintenance Organization)

HMOs often require members to select a primary care physician (PCP), a doctor who acts as a “gatekeeper” to direct access to medical services but this is not always the case. Except in medical emergency situations, patients need a referral from the PCP in order to see a specialist or other doctor, and the gatekeeper cannot authorize that referral unless the HMO guidelines deem it necessary.

Copay

Copayment or copay is a payment defined in the insurance policy and paid by the insured person each time a medical service is accessed. It must be paid before any policy benefit is payable by an insurance company.

Insurance companies use copayments to share health care costs to prevent moral hazard. Though the copay is often a small portion of the actual cost of the medical service, it is meant to prevent people from seeking medical care that may not be necessary.

Flex Plan

Your employer decides whether or not to sponsor a Flexible Spending Account, or “Flex Plan” as one of your insurance benefits.

Flex is an IRS-approved method of paying for your “out-of-pocket” Health, Dental, Vision, & qualified Over-The-Counter expenses with set aside “pre-tax” dollars.

Why Participate In a Flex-Plan?

Participation in a Flex-Plan saves you money by deducting the Flex set-aside dollars from your wages before taxes, making only the wages remaining subject to taxes. Through your employer’s Flex Plan, you can pay many of the following bills with your pre-tax dollars : Medical, Dental, Vision, qualified Over-The-Counter (OTC) medications, dependent care. By setting aside dollars for those expenses in a Flex Plan, most employees will save between 25% and 40% in taxes.

Hospitals:

  • Medical Care- includes primary physicians
  • Urgent Care-  when your primary physician isn’t available- holidays, weekends, evenings
  • Emergency Room- the cost is extremely high and the wait is generally very long.

Hospitals in San Diego

UCSD Medical Center

Sharp Memorial Hospital

Sharp Mary Birch Hospital for Women and Newborns

Scripps Mercy Hospital

Emergency Rooms

Urgent Care

Emergencies & Trauma

Pediatric emergencies

Doctors

Doctors finder at the Scripps

Doctors finder at UCSD

 

Multilingual Doctors

Dr Julie et Joseph Boulos: dentist (speaks English & French)

All Coast Dental is a family and cosmetic dentistry. Dr Joseph Boulos speaks fluently French and English.  Dr Joseph and Dr Julie offer a high quality dentistry using the most modern dental techniques and materials available for your dental care. They offer a wide range of services in general dentistry including periodontal laser therapy, cosmetic dentistry, root canal treatment, crown and bridge, pediatric dentistry, tooth removal, dentures, and teeth whitening.

2180 Garnet Avenue, Suite 1-K
Pacific Beach, CA 92109
Phone: 858-270-4904
http://www.allcoastdental.net/

Dr Veronique James : pediatrician (speaks English and  French)

Scripps Memorial Hospital
4150 Regents Park Row Ste 355
La Jolla, CA 92037
Phone : 858-457-2043

Dr Rita Feghali : pediatrician (speaks French, English, Spanish, Italian, German and Arab)

Vandever Pediatrics
4405 Vandever Avenue
San Diego, CA 92120
Phone : 619-516-6170

Dr Martin Kabongo : family doctor, pediatrician and gynecologist (speaks French and English)

UCSD Clinic
Scripps Ranch
9909 Mira Mesa blvd
San Diego, CA 92120
Phone: 858-657-7750