Doctors, insurance and emergencies in San Francisco

Getting covered

Most people are insured through an employer and choose a plan in a short window at the start of a job and again each autumn. Arriving in the country or starting work generally opens a time-limited special enrolment period. Outside employment, individual plans are bought through Covered California, the state marketplace, which also administers income-based subsidies.

• Deductible: what you pay before the plan starts paying.
• Out-of-pocket maximum: the annual ceiling on your own spending, and the number to compare plans on.
• HMO plans keep you inside one network and require referrals; PPO plans cost more and travel further.
• Kaiser Permanente combines insurer and provider — one system, its own doctors and hospitals.

Networks and the bills people do not expect

Networks are set per provider, not per building, so an in-network hospital can contain out-of-network clinicians who bill separately. Check the insurer's directory and then telephone to confirm, because directories go stale. Federal rules protect patients against some surprise out-of-network billing in emergencies, but the protection is narrower than the phrase suggests.

Where to go

Emergency rooms bill facility charges even for short visits, so they should be reserved for emergencies. Urgent care clinics handle the middle ground without an appointment and at far lower cost. Registering with a primary care physician takes weeks in the Bay Area, so do it before you need one; telehealth is widely offered by both employers and insurers and handles a lot of routine questions.

• 911 for emergencies.
• Urgent care for infections, minor injuries and anything that will not wait until Monday.
• Healthy San Francisco is a city programme that helps uninsured residents access care locally.

Prescriptions and dental

Drug cover works from a formulary that sorts medicines into tiers, and something dispensed routinely in your previous country may need prior authorisation here. Prices for the same generic vary between pharmacies, and discount cards sometimes beat the insured price. Dental and vision are almost always separate policies from medical cover — check whether your employer offers them at all.