I still remember the first days after I arrived in the USA as a cultural shock.
Among the various things that contributed to such an inconvenient mental state, there was one form sent by the Fellowship Coordinator: the health insurance.
Being raised in one of those countries having what Americans define, not without scorn, as "socialized health care", I never had any private health insurance. When I was sick, I knew I had to see my doctor (in the US, given the local love for acronyms that doesn't help foreigners, it is defined as PCP: Primary Care Physician), maybe he would refer me to a specialist, and I'd do some tests at the lab run by a friend of my mother's, just two blocks away from home. Everything necessary not to let this poor body of mine fall apart.
Now between me and the doctors, supposed to take care of me, there was something: I had to choose an insurance company. And a kind of policy. Should I prefer the insurance offered by the Smithsonian or look for another one? Should I go for HMO or PPO?
And above all: what are they talking about? What are HMO and PPO? How can I choose a company or another? Welcome to the jungle!
Of course I did what every homesick "socializedly health cared" foreigner would do: I just chose the insurance offered by the Smithsonian (acronym SI used hereafter).
I found out it was a PPO, which stands for Preferred Provider Organization. Private insurances are divided into two big kinds (there's something else, but I won't talk about that): PPO and HMO (Health Maintenance Organization).
I'm sure there are many differences, but the main one is that with an HMO you are obliged to have a PCP (you've got to cope with the acronyms, sorry). When you are sick, you go to your PCP, who decides your therapy or refer you to a specialist. You are not allowed to see a specialist without a referral (unless you want to pay out of your pocket). The insurance offered by SI doesn't work like this. With a PPO you are not obliged to have any PCP (though of course you can and should have one!) and you can see a specialist whenever you want to, without any referral.
There's a detail though. All these insurance companies have a network of health care providers (doctors, hospitals and other facilities): the providers in a company's network have special agreements with the company about their bills (the bigger the company, the bigger discount it gets). Once you are a member of an insurance, services obtained from an in-network provider are usually totally covered by the insurance, although you may have to pay a co-pay, that is a small contribution to the cost of the service (for example: $10 for an office visit, $50 for services at an Emergency Room). If the doctor or hospital is out-of-network, the insurance will pay only part of the bill (say 75%) if you have a PPO, or nothing at all if you have an HMO. Beware of the fact that with our PPO insurance you pay only 25% when out-of-network: 25% of A LOT can still be a lot. Whenever I need care now I know that I have to check on line, through the insurance web site which facilities are in the network.
I have also found out that I must always be prepared to unexpected and undesired surprises.
My very personal opinion is that one should always remember that the health care system is part of the market; the goal is not curing people, it's making money out of sick people.
Back to surprises. I happened to need immediate care, so I checked on line which not too far away facility was in the insurance's network. Sweet! There's a hospital 1 mile away. I'm in California without a car: I gotta walk there although it's summer and a quite hot day. Besides the fact that I had the fastest visit ever (I hadn't finished to name my symptoms, when the doc said what I should take and left), the surprise was in the bill, or better the bills. It can happen - but I couldn't imagine - that a hospital is in the network but not its ER doctors. Please, don't ask for logic. If you go to the ER in that hospital, the expenses related to the facility will be covered as in-network, the doctor's visit will be out of network and quite some money out of your pocket!
You will have another surprise if you decide to go to Harvard Health Services. I should never forget to be a predoc: nothing to do with Harvard, except using - not often really - its sport facilities. Harvard Health Service is not a hospital or a health care provider: it is a facility for the Harvard community, meaning all the people who have Harvard health insurance. Other potential customers/patients can receive only emergency care. Harvard Dental Services are open to the public.
By the way, it was with great disappointment that I found out our insurance does not include dental services, nor is any dental insurance available through SI. It does include vision coverage, which means I am allowed to see an eye-doctor or optometrist once a year to check my sight, and have discounts in buying contacts and glasses.
There's something funny about the vision coverage. It is provided by our insurance through a second company. If you need an ophtalmologyst for your annual sight check-up and pick him/her up in the medical insurance network, it is an out-of-network service! The doctor must be in the Davis Vision (the other company) network.
In principle, a medical condition (something that is pathological) should be covered by our medical insurance, even though it involves eyes or teeth. The rule of thumb is to check with Member Services if the specific condition you might have is covered or not, and at what level (50%, 80%, 100%?). "Hallo, there's this doctor who keeps saying I need some dunno-what therapy, will you pay for that?"
The first time I went to a pharmacy was also an experience. First of all a pharmacy in the US is a small supermarket, which is not necessarily bad. In my previous "socialized health" experience, a pharmacy used to be a place for medicines and health related products that are usually very good and very expensive. "It's sold only in pharmacies" used to mean "it's a pain for your wallet, but - man - this works". I never have this feeling in the US and I guess the fact that pharmacies sell cigarettes doesn't help me think they care about my health.
What I found odd was the way drugs are sold. There are two different places in the prescription drug area: one to order the medicine and the other one to pick it up. Apparently only over-the-counter drugs are pre-packaged: prescription drugs are stored in big amounts in the pharmacy and then packaged for every single customer. I had to wait about ten minutes to get a box of pills with a label on it and on the label my name, the doctor and the dosage. Fast food but slow drugs!
My resolution: I'll eat well, sleep long, do as much sport as I can (which doesn't mean much) and hopefully I won't have a stroke while yelling at the insurance Member Services on the phone.
Among the various things that contributed to such an inconvenient mental state, there was one form sent by the Fellowship Coordinator: the health insurance.
Being raised in one of those countries having what Americans define, not without scorn, as "socialized health care", I never had any private health insurance. When I was sick, I knew I had to see my doctor (in the US, given the local love for acronyms that doesn't help foreigners, it is defined as PCP: Primary Care Physician), maybe he would refer me to a specialist, and I'd do some tests at the lab run by a friend of my mother's, just two blocks away from home. Everything necessary not to let this poor body of mine fall apart.
Now between me and the doctors, supposed to take care of me, there was something: I had to choose an insurance company. And a kind of policy. Should I prefer the insurance offered by the Smithsonian or look for another one? Should I go for HMO or PPO?
And above all: what are they talking about? What are HMO and PPO? How can I choose a company or another? Welcome to the jungle!
Of course I did what every homesick "socializedly health cared" foreigner would do: I just chose the insurance offered by the Smithsonian (acronym SI used hereafter).
I found out it was a PPO, which stands for Preferred Provider Organization. Private insurances are divided into two big kinds (there's something else, but I won't talk about that): PPO and HMO (Health Maintenance Organization).
I'm sure there are many differences, but the main one is that with an HMO you are obliged to have a PCP (you've got to cope with the acronyms, sorry). When you are sick, you go to your PCP, who decides your therapy or refer you to a specialist. You are not allowed to see a specialist without a referral (unless you want to pay out of your pocket). The insurance offered by SI doesn't work like this. With a PPO you are not obliged to have any PCP (though of course you can and should have one!) and you can see a specialist whenever you want to, without any referral.
There's a detail though. All these insurance companies have a network of health care providers (doctors, hospitals and other facilities): the providers in a company's network have special agreements with the company about their bills (the bigger the company, the bigger discount it gets). Once you are a member of an insurance, services obtained from an in-network provider are usually totally covered by the insurance, although you may have to pay a co-pay, that is a small contribution to the cost of the service (for example: $10 for an office visit, $50 for services at an Emergency Room). If the doctor or hospital is out-of-network, the insurance will pay only part of the bill (say 75%) if you have a PPO, or nothing at all if you have an HMO. Beware of the fact that with our PPO insurance you pay only 25% when out-of-network: 25% of A LOT can still be a lot. Whenever I need care now I know that I have to check on line, through the insurance web site which facilities are in the network.
I have also found out that I must always be prepared to unexpected and undesired surprises.
My very personal opinion is that one should always remember that the health care system is part of the market; the goal is not curing people, it's making money out of sick people.
Back to surprises. I happened to need immediate care, so I checked on line which not too far away facility was in the insurance's network. Sweet! There's a hospital 1 mile away. I'm in California without a car: I gotta walk there although it's summer and a quite hot day. Besides the fact that I had the fastest visit ever (I hadn't finished to name my symptoms, when the doc said what I should take and left), the surprise was in the bill, or better the bills. It can happen - but I couldn't imagine - that a hospital is in the network but not its ER doctors. Please, don't ask for logic. If you go to the ER in that hospital, the expenses related to the facility will be covered as in-network, the doctor's visit will be out of network and quite some money out of your pocket!
You will have another surprise if you decide to go to Harvard Health Services. I should never forget to be a predoc: nothing to do with Harvard, except using - not often really - its sport facilities. Harvard Health Service is not a hospital or a health care provider: it is a facility for the Harvard community, meaning all the people who have Harvard health insurance. Other potential customers/patients can receive only emergency care. Harvard Dental Services are open to the public.
By the way, it was with great disappointment that I found out our insurance does not include dental services, nor is any dental insurance available through SI. It does include vision coverage, which means I am allowed to see an eye-doctor or optometrist once a year to check my sight, and have discounts in buying contacts and glasses.
There's something funny about the vision coverage. It is provided by our insurance through a second company. If you need an ophtalmologyst for your annual sight check-up and pick him/her up in the medical insurance network, it is an out-of-network service! The doctor must be in the Davis Vision (the other company) network.
In principle, a medical condition (something that is pathological) should be covered by our medical insurance, even though it involves eyes or teeth. The rule of thumb is to check with Member Services if the specific condition you might have is covered or not, and at what level (50%, 80%, 100%?). "Hallo, there's this doctor who keeps saying I need some dunno-what therapy, will you pay for that?"
The first time I went to a pharmacy was also an experience. First of all a pharmacy in the US is a small supermarket, which is not necessarily bad. In my previous "socialized health" experience, a pharmacy used to be a place for medicines and health related products that are usually very good and very expensive. "It's sold only in pharmacies" used to mean "it's a pain for your wallet, but - man - this works". I never have this feeling in the US and I guess the fact that pharmacies sell cigarettes doesn't help me think they care about my health.
What I found odd was the way drugs are sold. There are two different places in the prescription drug area: one to order the medicine and the other one to pick it up. Apparently only over-the-counter drugs are pre-packaged: prescription drugs are stored in big amounts in the pharmacy and then packaged for every single customer. I had to wait about ten minutes to get a box of pills with a label on it and on the label my name, the doctor and the dosage. Fast food but slow drugs!
My resolution: I'll eat well, sleep long, do as much sport as I can (which doesn't mean much) and hopefully I won't have a stroke while yelling at the insurance Member Services on the phone.
5 comments:
Hi Luc, God, I almost fell off the chair laughing - can't believe I want to head back to this. Course I never once visited a doctor in my three years at CfA. The thought gave me a headache ;) Excellent post! Elaine.
Thank's for the post!
second rule of thumb: go to the dentist every time you go back to your country. Actually, it may be cheaper even if you include the cost of the plane's ticket!
Excellent delivery of though what's the harsh reality of health care in US!
You could also think of getting a travel insurance from your home country (in Finland it was something ~300 euros per year) and not take any insurance in the states (now, that could cause you to pay more state taxes due to the new law stating that every Massachusetts citizen must have a health care but again it might be different for a foreign predoc. That's something that has to be found out. But let's face it... it's horribly complicated). Of course you need to go to your home country every year for a renewal of the insurance, but that you will probably do anyway. In this way, stay healthy overall and when something bad happens it's 'really' covered by your home country travel insurance which I'm sure is twenty times more reliable and customer-friendly than any acronym-firm you're going to bump up in here. Cheers, Karri.
hahahah, excellent point Karri! I never thought about that option.. but unfortunately, I'm sure they wont make it easy for you to just jump over the USA system... it's just too much money that won't go in to someone's pocket!
that is true, i had not thought about it, but when i got to the us on my first year as an exchange student i had an italian insurance. i'm just guessing here, but if you can prove adequate coverage: that is a coverage for at least $x where x is however much the smithsonian requires and an insurance that covers preexisting conditions and out of state emergency care etc etc (whatever the smithsonian decides you have to comply to...) you must be allowed to have that insurance, whatever country issues it. AND these insurances often cover your trip too if you need medical attention and you decide to get hospitalized in your home country!
Post a Comment