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Common terms for US health insurance

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  • Premium (premium): The amount you pay for medical insurance each month, usually monthly; the monthly cost is at least a few hundred dollars, and if the whole family buys insurance together, it may cost thousands of dollars per month cost of. Therefore, US health insurance premiums are very expensive.
  • Deductible: The amount you need to pay for medical services yourself before Medicare begins to pay for your medical care. For example, if the Deductible you purchased is $800, then you need to pay the initial $800 medical expenses each year, and the excess part will be paid by the insurance company, or the insurance company will pay you pro-rata together.
  • Co-Insurance: If you use Co-Insurance after you have paid the Deductible, the remaining medical expenses will be paid by you and the insurance company in the proportion of Co-Insurance. For example, if your Co-insurance ratio is 20%, then you need to bear 20% of the remaining medical expenses, and the remaining 80% is borne by the medical insurance company. Therefore, the smaller the proportion you need to pay, the higher the monthly insurance cost.
  • Co-pay (out-of-pocket, or out-of-pocket): The fixed amount you pay for a certain type of medical service. For example, with some health insurance plans, if you go to see your GP, you only have to pay a flat $30 each time, and beyond that, there are no more fees. Then this $30 is called “Co-Pay”.
  • In-Network: If your doctor is insured (or partnered with) by a health insurance company, you can get certain negotiated (i.e. discounted) rates. Therefore, when you choose a doctor, if the doctor belongs to the In-Network, you will save a lot of medical expenses. Also, some health insurance plans only allow you to use an In-Network doctor.
  • Out-of-Network: Contrary to the In-Network above, if your doctor does not have a contract with your medical insurance company, then the proportion of medical insurance coverage will be very low, and some medical insurance The company does not allow you to use an Out-of-Network doctor.
  • Out-of-Pocket Maximum: The maximum medical expenses you need to bear in the year of insurance, the lower the better. For example, if your maximum deductible is $10,000 after you pay $10,000, the insurance company will pay 100% of your medical expenses, but will not exceed the Maximum Benefit below.
  • Maximum Benefit: Refers to the highest premium that a medical insurance company can bear for some time.
  • Coverage: Medical expenses eligible for Medicare reimbursement.
  • Pre-Existing Conditions: If you have pre-existing health problems before purchasing medical insurance, some medical insurance companies may refuse to reimburse medical expenses for related diseases.
  • Waiting Period (Waiting Period): Some insurance companies require that the insured will not start reimbursement of medical expenses until a period after purchasing the insurance, which is called the “waiting period”.
  • Prescriptions/RX: Medications that require a doctor’s prescription.
  • PCP (Primary Care Provider): A family doctor who is responsible for all diseases except ophthalmology and dentistry. You also usually receive an annual physical examination from the family doctor. For some conditions, GPs may refer you to other specialists if they cannot handle them.
  • Specialist: Specialist, a specialist doctor specializing in a certain disease, such as an endocrinologist, a surgical income doctor, etc. Some health insurance plans require you to go through a referral from a family doctor before you can see a professional doctor; others do not.

What are the types of medical insurance in the US?

There are mainly the following types of medical insurance in the United States, among which the most extensive medical insurance in the United States is PPO and HMO.

PPO (Preferred Provider Organization)

The full name of PPO is Preferred Provider Organization, and its biggest features are as follows:

  • If you choose a doctor from In-Network, you need to bear less medical expenses;
  • You can also contact any specialist doctor yourself, no referral from a family doctor is required;
  • You can see an Out-of-Network doctor, and the PPO will also cover a portion of the medical costs;
  • However, your monthly health insurance premiums are higher;

Here are the advantages and disadvantages of PPO:


  • The PPO does not require you to choose a GP;
  • PPOs can reduce out-of-pocket medical costs and provide flexibility;
  • You don’t need Referral, you can see any expert;
  • Supports both In-Network and Out-of-Network;


  • Higher monthly health insurance costs for PPOs;
  • PPOs tend to be Deductible;
  • PPO supports Out-of-Network, but reimburses medical expenses at a lower rate;
  1. HMO (Health Maintenance Organization)

The full name of HMO is Health Maintenance Organization, which is also a medical insurance plan. It is medical insurance that only provides In-Network medical services. Its main features are as follows:

  • Compared with PPO, HMO has a stricter In-Network, and the cooperating doctors agree to charge lower medical fees;
  • HMO only pays the medical expenses of In-Network doctors, and does not bear any medical expenses of Out-of-Network, unless it is an emergency;
  • HMO requires the insured to designate a family doctor and see a specialist, requiring a family doctor Referral;
  • HMOs have lower monthly health insurance costs than PPOs;


  • Compared to other insurance plans, HMOs have lower monthly insurance costs;
  • HMOs generally do not require the insurer to bear the Deductible fee, or the Deductible fee is very low;


  • The medical treatment process for HMOs is cumbersome. To keep costs and insurance premiums down, HMOs require you to choose a family doctor who will coordinate all of your health care needs. If you are going to see a specialist, you must be referred by your GP;
  • HMO does not support any Out-of-Network medical expenses unless it is an emergency;

POS (Point-of-service)

The full name of POS is Point-of-Service, which is a fixed-point service plan that combines HMO and PPO medical insurance. The PPO created its own health care network, requiring insurers to appoint a family doctor who would refer them to In-Network specialists, thereby reducing medical costs.

POS has a relatively small proportion in the medical market. Its main features are as follows:

  • Compared with HMO, POS also allows you to see an Out-of-Network doctor, but you need to get a referral from a family doctor, so POS will bear more medical expenses;
  • Compared to PPO, POS offers cheaper fees, but its In-Network is smaller than PPO. Co-Pay for POS ($10~$25 per visit) is lower than Co-Pay for PPO. At the same time, you generally do not need to pay deductible fees for In-Network visits.
  • The monthly premium for POS insurance is between PPO and HMO.


The requirements for seeing whether a specialist has a family doctor recommendation are looser.

If you seek medical care at In-Network, the insurance company will cover most of the costs and you will pay less personally.

You can also go to an Out-of-Network clinic and the insurance company will reimburse some of the costs. POS gives members more options for self-medication.


  • In-Network has a limited number of doctors
  • POS still requires you to appoint a GP and requires the GP’s Referral

EPO (Exclusive Provider Organization)

The full name of EPO is Exclusive Provider Organization. If you use EPO’s In-Network doctor, you will pay less and do not need a referral from a family doctor. Moreover, the scope of the In-Network of EPO is larger than that of HMO.

EPO is not responsible for any Out-of-Network medical services, except in emergencies.


  • EPOs have lower monthly insurance costs. EPO plans are better for those who don’t need a lot of medical care and don’t want to spend too much.


  • Only include suppliers within the EPO network. You must only use In-Network doctors or clinics.


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