Private Health Insurance in the USA and Czech Republic

USA
Czech Republic
Insurance premium
Paid every month. Amount can depend on a strictly limited set of factors – age, state of residence, tobacco usage, number of insurees and plan category (percentage of co-insurance till out-of-pocket limit).
Varying premiums based on health status, gender or pre-existing conditions is strictly prohibited.
One time huge payment. Amount depends on the contract duration, gender, client’s age and health status. Insurance for small kids, pregnant women and elderly people is way more expensive than for clients between 6-44 years of age. Coinsurance should be 0% by law.
Varying premiums based on health status and pre-existing conditions is officially allowed by law.
Premium
regulation
Maximum premium can’t be more than 3 times different from minimum one.
80/20 Rule requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities. The other 20% can go to administrative, overhead, and marketing costs. For some insurers the split is even stricter – 85/15. If the insurer spends less than 80-85% on health care costs – clients get part of their money back.
Insurance companies must publicly explain any rate increase of 15% or more before raising the premium.
No regulations.
No upper limit for the premium is defined.
Annual premium growth is not regulated.
Insurance company can use any amount of collected premiums on outstanding business (and that is exactly the trend now with insurance companies spending 50-80% of the collected premiums on outstanding business and only 20-50% on the actual health care).
Contract start
Client chooses the insurance company and enrolls during open enrollment period, which is usually Nov – mid Dec. The insurance company can’t opt out of insuring the client.
Subject to insurance company’s approval. If the client is considered too risky he won’t be insured.
Contract termination
Insurance company can’t terminate the contract unless the client doesn’t pay the monthly premium.
Clients can terminate the insurance anytime, no penalties imposed.
Insurance company can terminate the contract any time within 3 months after insured event keeping 15-100% of the unearned premium.
Clients don’t have the option to terminate the insurance and get some part of the unearned premium back unless they die or join public healthcare system.
Insurance coverage limits
Current law bans both lifetime and annual limits on most covered health benefits.
An insured event can’t exceed the insurance limit which is usually 60 000 euro or 1 600 000 czk.
The lifetime limit is around 1 800 000 czk.
Guaranteed minimal coverage
Essential health benefits specified by ACA:
Ambulatory patient services.
Emergency services.
Hospitalization.
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment.
Prescription drugs.
Rehabilitative and habilitative services and devices.
Laboratory services.
Preventive and wellness services and chronic disease management.
Pediatric services, including oral and vision care for children.
Required coverage by Zákon č. 326/1999 Sb. § 180j:
Ambulatory patient services*.
Emergency services*.
Hospitalization*.
Maternity, but the law doesn’t ban insurers from making any maternity-related care subject to 3-8 months long waiting periods which they actively use.
Prescription drugs*.
Rehabilitative and habilitative services and devices*.
Laboratory services*.
Pediatric services, including oral and vision care for children*.
Repatriation.

* – claim is not recognized if connected to a pre-existing or uninsurable condition.
Exceptions from insurance coverage
No exceptions.
It is legally prohibited to raise insurance premiums for pregnant clients.
Any pre-existing conditions that the client had before the start of the insurance, for example chronic diseases.
Any genetic or congenital disorders, AIDS, HIV, any type of cancer, any sexually transmitted diseases, high-risk pregnancy (often multi-fetal pregnancy as well), IVF, autism etc even if the condition was discovered for the first time during the insurance period.
Non-mandatory vaccinations are not covered even if by czech healthcare regulations they should be covered by public insurance.
Mental health and substance use disorders.
Pregnancy and childbirth are subject to 3 and 8 months long waiting periods unless the case of special insurance for pregnancy\childbirth\neonatal care which is usually 5 – 8 times more expensive.
Children
Till age 26 kids are insured as dependents of a parent-policyholder.
Newborns are enrolled as dependents on parents’ insurance during a special enrollment period within 30-60 days after birth.
NICU stay is fully covered.
Children can’t be included into a parent’s private health insurance, each child should have a separate insurance contract in his name.
There is no adequate option to ensure a newborn of an employed mother without permanent residence (who already has pregnancy and delivery covered by her public health insurance). Mothers are facing a hard choice – to get a private health insurance for pregnancy\delivery\10 days at NICU max for an outrageous price of 70 000 czk on average or pay the costs for newborn hospitalization themselves, which is around 8 000 czk if everything goes by the book and up to 1 000 000 czk if it doesn’t.
Newborns can be ensured only after they are cleared to leave the hospital.
Legal regulations
ACA,
HITECH Act,
PSQIA,
MMA,
HIPAA,
EMTALA.
Individual states may have stricter regulations, like removing age as a viable factor for setting the premium.
Minimal requirements for the insurance contract are listed in Zákon č. 326/1999 Sb. § 180j , no real regulations apart from that.