| TERM | WHAT IT MEANS |
|---|---|
| Premium | The monthly amount you pay to keep your insurance active — regardless of whether you use any healthcare services that month. Heads up A lower premium often means a higher deductible. Make sure you know both numbers on your plan. |
| Deductible | The total amount you must pay for covered services before your insurance begins paying — preventive care is usually covered right away. Heads up This amount resets every January 1. If you have upcoming procedures, timing matters. |
| Copayment (copay) | A fixed, flat fee you pay for certain services — usually collected at the time of your visit. Example Your plan might charge $30 for a specialist visit, regardless of what the visit costs overall. |
| Coinsurance | Your share of the cost for a covered service, expressed as a percentage. This kicks in after you’ve met your deductible. Example With 20% coinsurance on a $500 service, you’d owe $100 and insurance covers the remaining $400. |
| Out-of-pocket maximum | The most you’ll ever pay for covered services in a plan year. Once you hit this limit, insurance pays 100% for the rest of the year. Heads up This is your safety net for high-cost years. Check this number on your plan — it varies widely. |
| In-network | Providers and facilities that have a contracted agreement with your insurance plan, meaning they’ve agreed on set rates. You pay less when you stay in-network. Heads up Always confirm a provider is in-network before your visit — your insurer’s online directory may not always be current. |
| Out-of-network | Providers who do not have a contract with your insurance plan. You can still be seen, but your costs will typically be significantly higher — and some plans don’t cover it at all. Heads up Some plans (like HMOs) may not cover out-of-network care except in emergencies. |
| Prior authorization | Approval your insurance company requires before they’ll cover certain services, procedures, or medications. Your provider typically submits this on your behalf. Important If a prior authorization is required and not obtained, your claim may be denied even if the service is medically necessary. Ask our office if your procedure requires one. |
| EOB (explanation of benefits) | A summary document your insurance sends after a claim is processed. It shows what was billed, what insurance paid, and what — if anything — you may owe. Heads up An EOB is not a bill. Wait to receive an actual bill from your provider before making a payment. |
