Making Sense of Health Insurance: A Plain Guide to Common Terms

Choosing or using a health plan is much easier when the words on the page make sense. Many people pay more than they need to, or skip care they are entitled to, simply because the terms are confusing. This plain guide explains the language you will meet most often, so you can compare plans and use your benefits with confidence.

What you pay and when

Your premium is the regular amount you pay to keep the plan active, whether or not you see a doctor. The deductible is what you pay for covered care before the plan starts sharing costs. A copay is a set fee for a visit or prescription, while coinsurance is a share of the cost you pay after the deductible. The out-of-pocket maximum is the most you will pay for covered care in a plan year.

The best health plan is the one you understand, because that is the one you will actually use.

Networks and referrals

An in-network provider has agreed prices with your insurer, so care usually costs you less. Going out of network can mean higher bills or no cover at all. Some plans ask you to choose a primary care doctor and get a referral before seeing a specialist, while others let you book directly. Check your plan's rules before you book.

Getting the most from your plan

Many plans cover preventive care, such as screenings, vaccines and yearly checkups, at no extra cost. Keep your insurance card handy, ask for prior approval for larger treatments when required, and review every statement you receive. If a claim is refused, you have the right to ask why and to appeal. Our team is happy to help you through it.

This article is for general information and does not replace advice from your own doctor. If you are worried about your health, please contact our team.