All You Need to Know About U.S. Health Insurance: A Basic Introduction
前言 | Introduction
從小在台灣長大的我，因為享有台灣全民健保的福利，從來沒有必要花心思去瞭解健康保險的各種規範與制度。14歲隨著父母移居至美國，見識美國醫療花費的龐大，也理解了美國的醫療制度跟台灣有很多的不同。其實我一直都很慶幸自己能經由四年藥學院的薰陶，讓我深度的理解美國的保險制度究竟有何不同。
我深知光靠一篇文章是無法涵蓋所有醫療保險相關的制度，但希望這篇文章能對像我一樣的新移民或在美的留學生提供幫助。如果有能進步又或者改善的地方，歡迎再底下留言或私訊我。
Having grown up in Taiwan, I was accustomed to the luxury of universal health insurance, sparing me the need to navigate the intricacies of health coverage. However, my perspective shifted when I relocated to the United States with my parents at the age of 14. The substantial healthcare expenses in the U.S. unveiled significant disparities between the healthcare systems of the two countries. I consider myself fortunate for the in-depth understanding gained through four years of pharmacy school education and hands-on experience in retail pharmacy.
While I acknowledge that a single article cannot comprehensively address all aspects of healthcare insurance in the U.S., my hope is that this piece proves beneficial to new immigrants or international students in the U.S. who share a similar background. If you identify areas that can be enhanced or suggest areas for progression, please feel free to share your thoughts in the comments below or message me. Your insights and suggestions are highly welcomed.
認識美國三大類醫療保險 |
Understanding the three main types of health insurance in the United States
Medical | Vision | Dental
首先，美國醫療保險主要可分為以下三大類：
First and foremost, medical insurance in the United States can be broadly categorized into three main types:
醫療保險| Medical Insurance： 這是最基本也最全面的醫療保險，涵蓋了一般的醫療就診需求，包括看病、住院、手術等。而這保險底下基本也會包含藥物保險。
This serves as the most fundamental and comprehensive health insurance, addressing general medical needs like doctor visits, hospitalization, surgery, and prescription drug coverage.
需注意的一點是，每個醫療保險方案(Medical Insurance Plan)都會有所差異。舉個例子來說，醫療保險方案就像是訂閱Spotify (又或者台灣的kkbox)的音樂服務一樣，其中有很多不同方案可供選擇。基礎方案包含的服務較少，而豪華方案有更多的福利而且涵蓋的範圍較廣。同樣，各個醫療保險方案所涵蓋的醫療範圍也有所不同。也因為如此，同樣的手術在不同的方案底下，有些可能涵蓋50%又或者更少。
It's crucial to recognize that each medical insurance plan differs. Consider medical insurance plans as comparable to a music subscription plan (e.g., Spotify), where basic plans offer fewer services, while premium plans provide enhanced benefits and broader coverage. As a result, various medical insurance plans may cover differing percentages of the same medical procedures.
眼科保險| Vision Insurance： 這項保險涵蓋了眼鏡、隱形眼鏡、或者視力矯正手術等眼科服務。
This insurance type encompasses services related to vision, including eyeglasses, contact lenses, or vision correction surgeries.
牙科保險| Dental Insurance： 主要涵蓋牙科治療的費用，包括例行檢查、洗牙、補牙、植牙、牙齒矯正等。
This insurance type covers dental treatment expenses, spanning routine check-ups, cleanings, fillings, implants, orthodontics, and more.
這三種類別的保險通常需要分開投保，也就是說，您可能需要分別選購醫療、眼科和牙科保險，或者根據個人需求和預算選擇其中之一。
如果在美國有工作，有些雇主會提供這三類醫療保險給員工申請。根據所在公司的不同，保險福利也會有所差異。有些雇主會全額支付員工的這三類保險，有些只幫忙負責支付一部份，剩下的餘額則交由員工自己支付。
Indeed, these three insurance categories are typically acquired separately, requiring individuals to make choices based on their specific needs and financial considerations.
For those employed in the United States, it's common for employers to provide options for these three types of health insurance. However, the specifics of insurance benefits can differ between employers. Some employers cover the entire cost of these insurances for their employees, ensuring comprehensive coverage. On the other hand, some employers may contribute a portion of the insurance costs, leaving the remaining balance to be covered by the employee. It's essential for employees to be aware of the details of their employer-provided insurance plans and understand their financial responsibilities for any remaining costs.
認識美國保險的基礎架構 |
Understanding the Basic Framework of Insurance in the United States
在美國，這三大類醫療保險基本上都有相似的結構。一般在申請保險時，每個保險計劃都會列明一些術語，包括保費（Premium）、自付額（Deductible）、共付額/掛號費（Copay）、醫療費上限（Maximum Out of Pocket），而我將逐一解釋這些概念。
In the United States, these three major types of health insurance generally have similar frameworks. Typically, when applying for insurance, each insurance plan will specify certain terms, including premium, deductible, copay, and maximum out-of-pocket expenses. I will explain these concepts one by one.
保險費| Premium: 是指自己所需定期向保險公司支付的金額。
This refers to the amount that individuals need to pay regularly to the insurance company, commonly known as the premium.
在美國，大多數公司通常每兩週發放工資，而醫療保險費用通常也以每兩週從工資中扣除（註：有很大部分的原因是因為從工資扣除可以省稅）。而保險金則會根據受保人的多寡而有所不同。基本上選購保險的時候會有幾大類供選擇(1)只保自己、(2)保自己與自己的配偶(共兩人)、(3)保自己與配偶加上孩子(全家)。
如果是在美留學生，保險費基本上則是由一學期(Semester)為單位來支付保險費。以前述Spotify例子為例，你可以把保險費想像成維持保險所需要的費用，要不然訂閱就會過期。
In the United States, most companies typically issue paychecks every two weeks, and health insurance costs are commonly deducted bi-weekly from these paychecks (note: this is largely due to the tax benefits associated with payroll deductions). The insurance premium varies based on the number of individuals covered. When choosing insurance, there are generally several options to select from: (1) coverage for oneself, (2) coverage for oneself and a spouse (a total of two persons), and (3) coverage for oneself, a spouse, and children (the entire family).
For international students studying in the U.S., insurance premiums are usually paid on a semester basis. Using the earlier Spotify example, you can view medical insurance premiums as the necessary cost to sustain the subscription plan; otherwise, the subscription will expire, leading to the termination of benefits.
自付額| Deductible:是指在保險公司支付你一部分的醫療費前，自己需要達到的醫療支付金額。
This refers to the amount of medical expenses that you need to pay out of your own pocket before the insurance company starts covering a portion of your healthcare costs.
自負額是選購保險方案時最為重要的一點。主要原因是，在達到自付額之前，保險公司不會支付你部分的醫療費用，而且支付的金額也僅限於達到自付額之後所超過的金額。因此，有時儘管某些方案的保險費較為便宜，但卻設有較高的自付額。若你因為追求便宜的保險費用而選擇此方案，在達到高額的自付額之前，保險公司不會協助支付任何醫療費用。
舉例來說，假設你的保險方案規定自付額為5,000美元，而你住院後的醫療費用為6,000美元。在這種情況下，你需要全額支付自付額中的5,000美元。剩餘的1,000美元則根據你在購買保險時所選擇的自付比例（共同支付比例/ Co-insurance）來支付。
Co-Insurance (自付比例): 達到自付額的费用後，需要自己承担的金額比例。
例如，如果自付比例為20%，那麼你需要支付剩餘的1,000美元的20%，即200美元，而保險公司將支付其餘的80%，即800美元。
The deductible is a critical consideration when choosing an insurance plan, as it determines the initial amount you must personally cover before the insurance company contributes to your medical expenses. The insurance coverage only kicks in once the deductible is met, and the reimbursed amount is limited to costs exceeding this deductible. Consequently, choosing a plan with lower premiums may sometimes mean accepting higher deductibles. If you select such a plan solely for its lower premiums, the insurance company won't assist with any medical expenses until you reach the higher deductible threshold.
For example, let's say your insurance plan sets a deductible of $5,000, and your hospitalization results in medical expenses totaling $6,000. In this scenario, you're required to pay the full $5,000 deductible upfront. The remaining $1,000 is subject to the co-insurance rate you selected during the insurance purchase.
Co-Insurance: This represents the percentage of costs you are responsible for after meeting the deductible.
For example, if the co-insurance rate is 20%, you would pay 20% of the remaining $1,000, which is $200, while the insurance company covers the remaining 80%, equal to $800.
共付額/掛號費| Copay:自己使用醫療資源時需要支付的固定金額。
A fixed amount that needs to be paid when using medical resources.
直譯為 "共付額”，這個費用將由保險公司和被保險人共同分擔一部分。我個人把這個共付額的概念細分為兩類：
就診相關：掛號費
因為每次接受醫療服務時都會產生問診費，這相當於台灣常見的掛號費。基本上，這個金額是固定的，並且通常會明確地列在保險卡上。這種費用主要是基於就診的次數計算，並且是無法避免的支出。
藥品相關：購買處方藥品時需要支付的固定金額。
藥品共付金額通常根據藥品的類別和種類而有所不同。不同的保險方案會對各種藥物做出不同的等級劃分（Tier），基本上是經過各個藥物在市場上的使用頻率做出分析而得出來的。如果藥品不在一級分類（Tier 1），其費用基本上會相對較高。而這種分級也會因為所選擇的保險方案而有所不同。
The copayment fee is a shared responsibility between the insurance company and the insured individual. I personally categorize this copayment into two types:
Visit-related: Registration Fee
The copayment fee is applied for each medical service sought. It is a fixed amount, typically clearly indicated on the medical insurance card. This fee is charged for every visit for medical care, thus, it is an unavoidable expense.
Medication-related: Fixed amount paid when purchasing prescription drugs.
The copayments for medications usually depend on the type of the drug. It is important to recognize that various insurance plans categorize drugs into different tiers, typically based on the market frequency of use for each drug. If a drug is not classified in the first tier (Tier 1), its cost tends to be higher. This classification also varies according to the selected insurance plan.
醫療費上限| Maximum Out of Pocket: 被保險人一年需要支付的醫療金額上限，超過後保險會全額支付你所有的醫療支出。
The annual maximum medical expenditure limit for the insured; once exceeded, the insurance will fully cover all your medical expenses.
醫療費上限的計算包括自付額（Deductible）和共付額（Copay）。一旦被保險人支付的醫療費用達到上限，保險公司將支付其餘的醫療費用的100%。
The calculation of the medical expense limit includes the deductible and copayment. Once the insured's out-of-pocket medical expenses reach the limit, the insurance company will cover 100% of the remaining medical costs.
如何解讀美國保險卡的資訊 |
How to interpret information on a U.S. insurance card.
申請好醫療保險後，保險公司會郵寄實體的保險卡到註冊地址，而保險卡主要會包含以下內容：
After successfully applying for medical insurance, the insurance company will mail a physical insurance card to the registered address, and the insurance card will primarily include the following information:
保險卡背後會有客服的聯繫方式，如果英文不流利可以向客服要求翻譯人員協助溝通。
The back of the insurance card will have contact information for customer service. If your English is not fluent, you can request assistance from translation personnel through customer service.
Rx Numbers:
首先值得一提的是，美國的基礎醫療保險會包含藥物保險，但這兩者的保險號碼在保險卡上是分開的。這是因為美國醫療體系將藥物費用和醫療費用分為兩個獨立的系統。因此，保險卡上通常會有幾行字帶著Rx開頭的BIN、PCN和Group Number。如果保險卡上沒有這些內容，有很多時候是因為保險公司會額外再寄一張獨立的藥物保險卡，帶有以上這些訊息。在藥局第一次領藥的時候，會請你展示保險卡，很大的原因是因為它們需要這些BIN、PCN和Group Number來上報給保險公司，以獲取藥物報價並告訴你這處方藥實際會需要的價錢。
Firstly, it's worth mentioning that basic medical insurance in the United States includes prescription drug coverage, but the insurance numbers for these two are separate on the insurance card. This is because the U.S. healthcare system treats drug costs (outpatient) and medical costs as two independent systems. Therefore, the insurance card typically contains several lines with Rx prefixes, including BIN, PCN, and Group Number. If this information is not on the insurance card, it's often because the insurance company sends a separate prescription drug card with these details. When picking up medication for the first time at the pharmacy, they will ask you to show the insurance card largely because they need these BIN, PCN, and Group Number details to submit to the insurance company for obtaining drug quotes and informing you of the copayment cost of the prescription.
當然，在少數情況下，如果連鎖藥局和保險公司有合作，他們可以利用你的名字、生日以及社會安全號碼從保險公司的系統中獲取你的醫療保險資料。但有些情況下，這些資訊有可能無法即時更新，系統連線問題而無法取得，又或者受保人在保險公司系統中的生日與名字有些許差異而無法獲得。也因此，強烈建議在領藥時主動提供最新的保險卡資料，以確保藥局能及時且正確地鎖定你的藥物保險方案。
Of course, in some cases, if there is cooperation between chain pharmacies and insurance companies, they can retrieve your health insurance information from the system using your legal name, birthday, and social security number. However, in certain situations, this information may not be instantly updated, there may be system connectivity issues preventing retrieval, or the insured person's birthday and name in the insurance company's system may have slight discrepancies, making it difficult to obtain. Therefore, it is strongly recommended to proactively provide the latest insurance card information when picking up medication to ensure the pharmacy can promptly and accurately access your prescription drug insurance plan.
認識醫療保險方案兩大類別& HMO/PPO 的差異 |
Understanding the Two Major Categories of Health Insurance Plans & Differences between HMO/PPO
這三大類的保險除了基於上述的那些基礎結構，選定保險方案時，會遇到下列這兩大類型的醫療保險方案：
Apart from the framework structures mentioned earlier, when choosing an insurance plan, you will come across two primary types of health insurance plans:
HMO（健康維護組織| Health Maintenance Organization）：需選擇一位主治家庭醫生（Primary Care Physician，簡稱PCP），需要獲取轉診單才可以再特定的專科就診。
Requires choosing a primary care physician (PCP) and obtaining a referral before seeking treatment from a specific specialist.
優勢：HMO通常有較低的保險費用 （Premium）和較少的自付額 （Deductible）。
Advantages: HMOs typically have lower insurance premiums and lower deductibles.
PPO（首選提供者組織| Preferred Provider Organization）：可以自由選擇醫生和醫院，不需要經過家庭醫生開轉診單。
Provides the flexibility to choose doctors and hospitals without requiring a referral from a primary care physician.
優勢：因為不需要經過家庭主治醫生轉診，靈活度較強。但通常伴隨著較高的保險費用（Premium）和自付額（Deductible）。
Advantages: Offers greater flexibility as there is no requirement for a referral from a primary care physician. However, usually comes with higher insurance premiums and deductibles.
HMO和PPO這兩大保險方案都建立在一個名為網路（Network）的概念上，有點類似電話網內跟網外互打收費不一的概念，而在醫療領域中，網路（Network）這個名稱主要是告訴你與這間醫療保險公司有合作的醫療機構和醫生有哪些。
Both HMO and PPO plans operate on a network concept, much like making in-network and out-of-network calls in telephone networks. Costs tend to be higher for services outside the network, similar to international calls or calling someone using a different service provider. In the healthcare sector, the term "network" primarily refers to the medical facilities and doctors with whom the insurance company has established partnerships.
網內（In-Network）：指的是與保險公司有協議的醫院、診所、醫生等。
Refers to hospitals, clinics, and doctors with whom the insurance company has agreements.
通常，在這些”網內”的醫療機構給予”網內”醫生看診，保險公司會支付較高的比例，而自己所需支付的醫療費用會相對較低。
When seeking care from in-network doctors at in-network healthcare facilities, the insurance company typically covers a higher percentage, resulting in lower out-of-pocket expenses for the insured.
網外（Out-of-Network）: 是指未與保險公司合作的醫療提供者。
Refers to healthcare providers who do not have agreements with the insurance company.
在這種情況下，保險公司支付的比例通常較低，而被保險人需要支付較高的自付額。有時候，有可能需要自己完全給付醫療費用。
In such cases, the insurance company typically covers a lower percentage, leading to higher out-of-pocket expenses for the insured. In certain instances, it may be necessary for the insured to bear the entire cost of medical expenses.
因此，在選擇醫療保險方案時，需要了解自己所在的區域有哪些醫生/醫療機構被保險公司的網路所涵蓋。在相對偏僻的區域，有時候某些保險公司的涵蓋範圍可能會比其他公司更廣泛。以就醫的便利性為考量，也是選擇適合自己的醫療保險時需要注意的一點。
Hence, when choosing a health insurance plan, it's crucial to grasp which doctors/healthcare facilities in your local area are included in the insurance company's network. In more rural areas, some insurance companies may provide broader coverage than others. The convenience of accessing medical care is also a crucial factor to consider when selecting a health insurance plan that meets your requirements.
結語 | Conclusion
我深知美國醫療保險這個領域是個浩瀚的無底洞，光靠文字有時候很難精確的表達又或者完整的傳達完其中的複雜性。如果你有任何問題或建議，請不吝留言告訴我。我們一起學習，一起進步，讓了解美國醫療變得更簡單。感謝你一直以來的支持和關注！
I know that learning about U.S. healthcare insurance is like exploring a vast area with so much to discover. It's challenging to rely solely on words to fully express or simplify the complexity of the concepts. If you have any questions or suggestions, please don't hesitate to leave a comment and share your thoughts. Let's embark on this learning journey together, striving to make the understanding of U.S. healthcare more straightforward. Thank you for your ongoing support and attention!
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