Doctors and dentists in the USA: who pays and how to cut your costs

American doctors are good, and they are expensive. If you know where to go with which problem, which practices are in your insurer's network and what rights you have when the bill arrives, you pay a fraction of what others pay for the same treatment.

Your first doctor's visit in America brings two surprises. The first is often a pleasant one: a modern practice and a doctor who takes time for you. The second arrives in the mail weeks later: a bill, often from several senders, with items nobody mentioned beforehand. What you need to know about the American healthcare system lies between those two experiences.

This guide explains how networks and insurance fit together, what a doctor's visit costs, when to see your primary care doctor, go to urgent care or head to the ER, what rights you have when the bill comes, how to get prescriptions and what is different at the dentist. Which insurance suits you is covered in separate articles, such as Health insurance in the USA: costs and the guide to health insurance by age. When you can and should get insured is shown in the checklist for your first 90 days.

1Insurance first, then the doctor

In most of Europe you pick a doctor and show your card. In the USA, the search starts with your insurer. Every insurer has a network: the doctors, clinics and other providers it has signed contracts with. If you see a doctor in that network, the price your insurer negotiated applies, and you pay your share under your plan.

See a doctor outside the network and it gets more expensive. Many plans then pay nothing at all, others only a smaller share. You cover the rest, and the doctor is not bound by any negotiated price. healthcare.gov gives the example of a 40 percent share out of network, which is usually higher than in network.

The kind of network you have depends on the type of plan. Some plans require a referral from your primary care doctor before you see a specialist, others do not. The differences are explained in the article HMO, PPO, POS and EPO, and the terms around deductibles and percentage shares in the articles on the deductible and coinsurance.

2What a doctor's visit costs

Fixed fee schedules exist in the USA only in government programs such as Medicare. Otherwise every provider sets its own prices, and every insurer negotiates its own discounts. Government surveys give you a benchmark. According to the Medical Expenditure Panel Survey by the federal agency AHRQ, total spending on an office visit to a doctor in 2016 averaged $265, with a median of $116. A primary care visit averaged $186, an orthopedist $419. These are older figures and show the order of magnitude, not today's price.

For visits where the patient paid something out of pocket, the median share was $30. Hospital stays are a different league: healthcare.gov cites up to $7,500 to treat a broken leg and around $30,000 for a three-day hospital stay. That is exactly why there is a cap on your own costs, the out-of-pocket maximum. For Marketplace plans it is at most $10,600 for an individual and $21,200 for a family in 2026, and at most $12,000 and $24,000 in 2027. Once you reach it, your insurer pays in full for covered in-network services for the rest of the year.

Your premium does not count toward the cap, and neither do services your plan does not cover. If you are treated out of network, you can pay considerably more. That is the single most important reason to take the network seriously.

3Finding a primary care doctor

Find your primary care doctor, your Primary Care Physician, while you are healthy. They are your first port of call for preventive care, vaccinations, non-urgent illnesses and ongoing treatment, and under some plans they write your referrals to specialists. If you only start looking once you have a fever, you are searching under pressure, and a practice taking new patients is not always available the same day.

The easiest way to search is through your insurer's directory. Call the practice before booking and ask whether it takes new patients and accepts your plan. Directories can be out of date, and a quick question on the phone can save you an out-of-network bill.

A benefit many people do not know about: preventive services such as vaccinations and screenings are usually covered with no cost sharing at in-network doctors, even if you have not yet met your deductible. healthcare.gov points out that this is not guaranteed in every case. So when you book, ask whether the appointment will be billed as preventive care. The basics are also covered in the article 5 facts about primary care.

4Urgent care, ER or primary care?

Between your primary care doctor and the hospital, the USA has a third level: urgent care. It means treatment for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe that it belongs in the ER. A cut, an ear infection on the weekend, a sprained ankle: that is urgent care. You usually do not need an appointment, and here too, check beforehand whether the facility is in your insurer's network.

The emergency room is for real emergencies: chest pain, shortness of breath, serious injuries. In an emergency, dial 911. Under the federal EMTALA law of 1986, hospitals with an emergency department that participate in Medicare must screen anyone who comes in with an emergency and stabilize them, whether or not they can pay. That protects you in a crisis, not from the bill afterwards.

Some plans also include telehealth, meaning a video call with a doctor. Whether yours does, and on what terms, is set out in your plan documents. The table sums up where to go with which problem.

5Protection from surprise bills

Here is an example: you go to an in-network hospital, and a doctor you never chose bills you out of network. The No Surprises Act protects you against this. It applies to most types of health insurance and protects you from surprise out-of-network bills for emergency room visits, for care connected to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center, and for air ambulance services.

If you have no insurance or are not using it, you have a separate right: providers generally have to give you a Good Faith Estimate of the cost. You get one if you book at least three business days (Monday to Friday) in advance or specifically ask for it. If the bill later comes in at least $400 above the estimate, you can dispute it.

Check every bill before you pay. Compare it with your insurer's statement, the Explanation of Benefits, which shows what was charged, what was paid and what your share is. If the bill is higher than your share on the statement, talk to the practice; questions about what is covered go to your insurer.

6Prescriptions and medication

An American pharmacy will generally not fill a prescription from your home country; very few are allowed to, and each state sets its own rules. For your arrival, the FDA lets foreigners without a green card bring or have shipped a 90-day supply; if you stay longer, you can have further medication sent to you. Bring a copy of your prescription in English, and for medications classed as controlled substances in the USA, check the additional rules of the DEA, which US Customs and Border Protection (CBP) also refers to.

If you want to pick up medication at an American pharmacy after your first three months, you need a local doctor to write a new prescription. One more reason to find a primary care doctor early. Bring a list of your medications with the active ingredient and dosage to your first appointment, because brand names often differ between Europe and America.

7The dentist

Health insurance usually stops at the dentist's door. In the USA, adult dental care is not an essential health benefit, and plans do not have to offer it. For children up to 18 it is different: dental care is an essential benefit, and on the Marketplace, dental coverage for the child must be offered either as part of the plan or as a separate plan. You still do not have to buy it.

Adults can buy separate dental insurance, both on the Marketplace and on the open market. It comes with its own premium and may have waiting periods during which certain treatments are not yet covered, even though you are already paying the premium. Ask about this carefully before you sign up.

For cheaper treatment, try the dental clinics at universities. Students treat patients there under close supervision by experienced, licensed dentists, and the treatment costs less; the National Institute of Dental and Craniofacial Research at the federal health agency NIH recommends this too. A second option is the federally funded health centers, where you pay according to your income. And one simple tip: before you move, get everything done that is due anyway.

8Seeing a doctor without insurance

If you see a doctor without insurance, for whatever reason, you are a self-pay patient in the US. That is neither illegal nor unusual, but it gets expensive if you don't plan for it. When you book, ask for the self-pay price and for the Good Faith Estimate you are then entitled to. Ask explicitly for a self-pay price before any treatment begins.

For simple treatment, the federally funded health centers are also an option. The federal agency HRSA runs a search tool for health centers near you, and there the price depends on what you can afford. In an emergency, the EMTALA law applies regardless of insurance.

The better solution is never to be without insurance in the first place. If you move to the US from abroad, you can usually get covered on the Marketplace within 60 days of your move, even outside the annual enrollment period. Until that coverage kicks in, keep travel or international health insurance running. The checklist for your first 90 days shows how to organize those first months so there is no gap.

In short

• In the US, your insurer's network comes first: in-network doctors have contracts with it, and out of network you usually pay more.
• According to the federal MEPS survey, an office visit cost $265 on average in 2016, and $186 with a primary care doctor; healthcare.gov cites up to $7,500 for a broken leg.
• Preventive care with an in-network doctor is usually free of copays, urgent care handles what is pressing but not an emergency, and the ER handles real emergencies.
• The No Surprises Act protects you from surprise out-of-network bills; without insurance, you are entitled to a cost estimate and can dispute a bill that exceeds it by at least $400.
• Dental care for adults is not an essential benefit; university dental clinics offer cheaper treatment.

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