We initially planned to have a couple of blog posts on health care for Canadians living in the U.S. and then realized we’ll need several to cover the *sizable* topic. We figured out that a glossary of terms would be a good place to start. Large bureaucracies like hospitals and health care love their acronyms and jargon! So we hope this helps you as you navigate the system here in the U.S.
As you peruse the list below, you’ll probably realize that most of the terms relate to health insurance, rather than actual visits to a doctor. Because healthcare insurance is privately funded and typically paid for by your employer (A big contrast from Canada where your province covers most of the costs and your employer covers extended health benefits), and because the U.S. is a large country, how medical care gets accounted and paid for can be pretty complicated.
The Affordable Care Act (Obamacare) was passed by Congress in 2010 and was arguably Obama’s signature achievement. It did a whole bunch of things, including ensuring that everyone had access to insurance, mandating that folks have coverage and (arguably) driving up the cost of that coverage.
The current administration has been unsuccessful in dismantling the ACA (a plank in Trump’s campaign platform) but has taken a number of measures that make things even more complicated than they were.
The “Consolidated Omnibus Budget Reconciliation Act” (Now that is a mouthful) ensured that, if you left a job you could take its healthcare insurance with you. A couple of things to keep in mind: a. The coverage is good for 18 months; b. You have to pay 100% of the insurance premiums, which, if you are older or have a large family, can be sizable.
Some doctors offer a concierge service where, for a fixed fee per month you can have unlimited access to them and their staff. Appointments are less rushed under conventional plans and give you time to focus on specific health issues you have.
The small(ish) amount your insurance has you pay for doctor visits and prescriptions. This is similar to the deductible you pay using your extended health benefits back in Canada (for example, the $20 you must pay to fill a prescription, or the $80 you must pay when visiting the dentist for a procedure). Sometimes it can be cheaper to buy drugs yourself (i.e not use your insurance) than fork out the $40 co-pay. Weirdly, insurance companies and pharmacies can make money off your co-pay.
A word of advice: ask LOTS of questions about the co-pays associated with your insurance plan and what it would cost if you chose not to use your insurance to pay for the service.
Like your car insurance back home, your health insurance plan here will have deductibles below which you have to pay costs yourself. The schedule for what counts and what the deductible for your plan is can be complicated: since the passage of the ACA (Obamacare) deductibles have gone up as a way of keeping overall insurance premiums down. (My wife and I have to spend about $10,000 annually before our health insurance picks up anything.) Deductible triggers are sized by both individuals and families.
For example, assume that you may have a deductible of $3,000 per each of the four individuals in your family and total family deductible of $10,000. Imagine the unhappy (and unlikely) events as follows. Your teenage son breaks an ankle showing off to his girlfriend in Tahoe in January and you spend a night at the ER in Truckee. You get a bill for $3,000 - you’ll pay for it all (it’s right at the individual deductible amount).
Then in February, your 11 year old daughter ends up in the ER with some vague asthma attack; the bill for that visit is $5,000 - your insurance will pick up $2,000, as you have breached the invidiual $3,000. Then in June your spouse has to go for tests that cost $2,500 - you’ll pay full freight on these as they are below the individual $3,000 limit you each carry. Your family has now spent $8,500 on medical expenses, nearing your family’s $10,000 cap. Finally, in October your doctor recommends an MRI and ultrasound for some knee pain you are experiencing, which you have done at the local hospital, without shopping around, and you get a bill for $10,000. You are above your individual deductible amount by $7,000 and above your family cap by $8,500 - your insurance will cover this for $7,000 and any additional expense your family has will be covered this year too.
FSA or HSA
A Flexible Spending Account or Health Savings Account enables you and your employer to put aside pre-tax funds for health and childcare related expenditures. You have to estimate how much money you want deducted from your paycheck accurately as you lose any unused funds at the end of the calendar year. Handy for predictable expenses like child care, prescription drugs and regular therapy.
High Deductible Health Plans have a much higher deductible than regular plans, as a way of keeping premiums down. Since the passage of ACA (Obamacare), many plans have shifted to this mode. High deductibles cannot be more than $6,650 for an individual or $13,300 for a family.
In Network / Out of Network
Insurance plans typically have networks of doctors they contract with to provide service; if you stay within this network of doctors, specialists and the hospitals they work in, their standard coverage and deductibles apply. If you go “Out of Network” - say to see a specialist who isn’t affiliated with that hospital or health insurance provider- you likely pay more through a higher deductible.
A Preferred Provider Organization means your insurance provider encourages you, the user, to choose health care providers and hospitals in a network of participating doctors and hospitals. In essence, this is the insurance providers own “In Network” and tends to be larger than an HMO. Because you are offered more choices and greater flexibility in a PPO, its premiums are higher than the equivalent insurance through an HMO.
This stands for Health Maintenance Organization. HMO plans give you access to a network of doctors and specialists who only work for or contract with that specific HMO (Kasier is the great granddaddy of HMOs). It generally won't cover out-of-network care except in an emergency. HMOs often provide integrated care and focus on prevention and wellness.
A Health Savings Account enables you and your employer to save money pretax that can be used for healthcare out of pocket costs. Unlike an FSA, the money in this account roles over from one year to the next (i.e. you do not lose unspent money.)
This is a State and Federal-run program that provides health care coverage for people who have very low incomes.
This is government provided healthcare insurance for folks over the age of 65, which is run a lot like the Canadian healthcare system.
The bugaboo of the U.S. health insurance system. Prior to the ACA (Obamacare), an insurance company could refuse an applicant coverage if you had a pre-existing or ongoing illness. A couple of things made this complicated: a) The list of what was considered pre-existing was fluid so you never quite knew whether you were in or out; and b) As folks got older, just about everyone ended up with a pre-existing condition (e.g. High blood pressure, depression, diabetes, cancer in remission). Note that pre-existing conditions were not a factor with employer provided insurance, and while you have COBRA.
With the ACA the issue of pre-existing conditions went away, although they seem to have made a partial comeback under current legislative changes.
Urgent care clinics have been developed by healthcare providers to take care of folks who need medical help but don’t need the services of an emergency room. The level of care can be mixed but it beats waiting in an ER or for an appointment with your doctor.
Hugh Morgan grew up in Calgary and has lived in the Bay Area for 27 years. He’d be delighted to answer any questions you have about life in the Golden state: you can reach him at email@example.com.