An Australian’s Guide to Health Care in New York

Moving to New York exposes a number of things about American culture that seem quite foreign to Australians. For the most part, it’s not something that impacts your day-to-day life. And then there’s healthcare, which can be confusing, expensive and give you Australian Medicare withdrawals like nothing else.

I’m not going to try to explain the health system for you or how it works – there aren’t enough pages on this website, plus, let’s face it, I have no clue. But I have discovered a few things over the past few years that have made navigating the health system a little bit easier. Read on for an Australian’s guide to health care in New York. It’s not an exhaustive list, but hopefully it’s helpful!

Zocdoc

I didn’t really see the point of Zocdoc when I first moved to New York. In Australia, I had always managed to find reliable doctors and knew I could go to them for anything, how much it would cost, that they would take my insurance.

In New York, I found, it wasn’t that simple. Not all doctors take your insurance. So even if someone recommended a doctor to me, there was a chance I couldn’t see them.

Enter Zocdoc. It’s like Yelp, but for doctors. Zocdoc allows you to see patient ratings for doctors on everything from knowledge and experience, through to timeliness and bed side manner. But then – and this is the best feature in my opinion – Zocdoc layers over the reviews an insurance filter, so you know before booking that the doctor (or dentist, physio, therapist, OBGYN, etc) will take your insurance. You can then book directly on the site and can can even complete your forms online to save time at the appointment.

You’re welcome.

Prescriptions

The first time I obtained a prescription for medication here I was quite confused because I never physically received anything. The doctor’s receptionist asked for the address of “my pharmacy”. To prevent fraudulent prescription practices, doctors must send scripts direct to pharmacies, who then hold on to it. Which is fine, until it’s not fine. Like when you’re out of town. Or working late. Or the one near you isn’t open on a Sunday. Or doesn’t have what you need.

Capsule is something I discovered recently. It’s an online pharmacy that offers same-day free delivery of your prescriptions. Depending on the medication and your location they can deliver as quickly as within 4 hours to any address you supply when someone is available to collect. If you have questions you can live chat or text with a pharmacist – and it really is a pharmacist, not a robot. Best feature? They deal with your insurance company directly.

The costs of medications don’t seem to be as regulated here as they are in Australia and can vary by drugstore, even when it’s in the same chain. So it’s worth calling around if you find that one store seems to be priced consistently higher. One of our AWNY members recalls a medication she needed during pregnancy that was not covered by her insurance. For the same chain drugstore, for the exact same medication, from the same pharmaceutical company, the price varied between $120 per month and over $700 per month.

You can take some of the hassle out of ringing around too by using GoodRX, which compares medication prices and sources up to date coupons you can apply at the time of paying.

Question every bill before you pay it. Every bill.

You’ve probably heard of medical bill horror stories – or experienced your own – occurring in the USA. Unsuspecting patient A receives a huge bills for seemingly rudimentary service B.

For me, it was the $800 bill for “acne surgery” performed by a dermatologist during a skin cancer scan. Now, let’s be clear, the dermatologist popped a pimple on my nose. Nothing about what he did warranted such a bill. Pretty freaked out, I queried the cost with the receptionist and was told “not to worry about it”. My insurance company covered a chuck of the cost, and I was never contacted again to pay anything.

This is the loop-hole in the health insurance system here that causes prices to remain high. Doctors charge crazily high prices in the hope to get a maximum amount of coverage from your insurer. Technically, you are meant to foot the remainder of the bill, but oftentimes you won’t be asked to. Which is good, except that it was that crazy high cost initially that means your premiums will likely go up next year. The moral of the story? I can’t help to fix the broken US health system, but I can advise you to question your bills before paying them. Always!

Insurance 

Let’s face it, medical insurance in the US is painful. Unlike any other insurance you buy, even after you pay premiums, there are complicated, continuing costs. I’m not able to provide guidance on what insurance you should get. But I can help you with some of the common terms you’ll encounter and a few small titbits.

Domestic partnerships mean you can use their insurance

It was pretty disappointing to learn that the E3 visa didn’t extend to non-married couples. But it was bloody brilliant to learn that many health insurance companies do acknowledge defacto relationships! Here, it’s known as a “domestic partnership”.

If you or your partner has insurance that recognizes domestic partnerships, it means that you can both go under the one plan – which can be very cost effective. Better yet, many insurance firms recognize same-sex domestic partnerships.

All you’ll need to show is that you live together (joint lease), have shared finances (a joint bank account suffices) and sign a stat-dec saying you’re in a long term partnership with them.

Preventative care can pay

With rising health care costs in the US, most insurance firms are tickled pink if you take preventative steps for your health – it costs them less in the long run. So make sure you investigate what freebies or reimbursements your insurance offers by having a thorough squiz of their website. Many, for example, will give you $200 if you go to the gym 50 times in a 6-month period (that’s roughly twice a week…you can do it!) or will give you cash incentives for completing steps in their preventative care checklist.

Be wary of multi-provider procedures

If you’re having any procedures that involve multiple providers, it’s worth confirming that all of them take your insurance. For example, while your doctor may take your insurance, if the anaesthesiologist doesn’t you could be hit with a surprise bill of several hundreds of dollars. If you’re not sure, confirm with the doctor first.

Insurance Glossary of Terms

Insurance Premium

Just like in Australia, this is the price you pay for your insurance coverage, typically charged monthly. In the US, however, premiums can be eye-wateringly high and can fluctuate from year to year quite significantly. An employer that offers good benefits will take care of a big chunk of your premium, so consider that when looking for work.

In-network

Providers or health care facilities that are part of an insurance plan’s network of providers are considered in-network. Being in-network will typically result in much lower fees for the patient, because they have agreed to charge specific, lower rates. It’s really important to know whether your provider is in-network before you accept their service.

Out-of-network

As the name suggests, this is the opposite of in-network. Though there are some exceptions, in many cases, an insurance company will either pay less or nothing at all for services you receive from out-of-network providers. So even after paying an insurance premium, you could still be on the hook for the whole bill. Consider yourself warned!

Deductible

The amount you pay out-of-pocket for medical services before your insurance kicks in. Think of it like the excess you might have to pay on your car insurance. So, if you’re deductible is $1,000 you will pay $1,000 from your own money on medical costs before your insurance will cover anything. But, many insurance plans will pay for certain services (especially preventative care) even before you reach your deductible amount. It’s worth noting that a deductible can be different for individuals versus a family plan, and often you’ll have a different deductible for medical services and prescriptions.

Co-payment / Co-pay

The fixed dollar amount you pay for a covered health care service after you’ve paid your deductible (see above). Think of it like the “gap amount” from your Australian days. These can vary greatly, even within the one plan, depending on the service, like lab tests, x-rays, drugs, specialists, etc. For a given service, such as a doctor’s visit, your co-payment may be $45. As you would expect, an insurance plan with low premiums will typically have a higher co-payment, and plans with high premiums will have lower co-payments.

Co-insurance

Almost the same as a co-payment or co-pay (above), except that instead of being a set dollar amount, this will be a percentage. For a given service, such as a doctor’s visit, your co-payment may be 20% after you’ve paid your deductible. As you would expect, an insurance plan with low premiums will typically have higher co-insurance amounts, and plans with high premiums will have lower coinsurance.

Primary Care Physician (PCP)

Similar to a GP back home, this is a generalist doctor you can go to as a first point of contact when you’re unwell. Unlike Australia, where GPs handle a fairly broad scope of services, the US follows a specialist model and you may be referred to a specialist for seemingly minor conditions. For many insurance plans, you will need a referral from a PCP to see a specialist, otherwise your fees will be higher, or not covered at all. If in doubt, contact your insurer to clarify their requirements.

It’s definitely worth finding a PCP as you never know when you’ll need a referral to a specialist, which could even be a physio for something as routine as a stiff neck. See above information about Zocdoc for help to find one.

Out-of-pocket Limit

Thankfully, the government has set limits to the amount a person can be liable for on a marketplace plan. The out-of-pocket limit is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, co-payments, and co-insurance, your health plan pays 100% of the costs of covered benefits. This doesn’t include premiums.

Open Enrolment

A small window of time when those people who use the health insurance marketplace are allowed to opt in for, or change, health insurance for the year ahead. Unless you have a “qualifying life event” you can’t change insurance for the next 12 months, so it’s important you consider your options, and what might be on the horizon, before making any enrolments.

A small note on hospital gowns

Before leaving Australia I could count on one hand the number of times I had worn hospital gowns. And all of these occurred in a hospital when I was about to undergo some form of operation. Since moving to New York four years ago I have been asked to strip naked and adorn a hospital gown at least 15 times. For super routine stuff, like a check up with my GP (primary care physician) and a visit to an allergist (for a blood test). It’s weird.

Just thought I’d share in case you’ve had the same experience and were concerned.