Health Insurance Terms & Definitions

Benefit: A general term referring to any service (such as a physical therapy visit, laboratory test, surgical procedure, etc.) or supply (such as prescription drugs, durable medical equipment, etc.) covered by your health insurance plan.

CoInsurance: This is a percentage that is your responsibility to pay. A common co-insurance split is 80/20. This means that the insurance company will pay 80% of the services and you are required to pay the remaining 20%.

CoPay: A copay is a fixed amount that you are required to pay at the time of service.

Deductible: This is the amount that you will need to pay before any benefits will be paid by your health insurance provider. For some plans, the deductible doesn’t apply, meaning that coverage can begin immediately without having to meet the deductible. This amount resets each year (or plan year), so once you’ve met it, be sure to use your benefits!

In-Network: Providers and clinics that have a contract with each other are considered in-network. What this means for you, is that your copay and deductible may be lower, coinsurance may be higher, and overall cost of treatment may be lower.

Out-of-Network: Clinics without a contract with a health insurance provider are considered out-of-network.

Out-of-Pocket Maximum: All payments that you make out of your own pocket, typically including copays, coinsurance, and deductible, goes towards your out-of-pocket maximum.. Once your maximum is reached, your health insurance provider covers 100%. As the year ends, be aware if you’ve reached this amount. If so, it’s a great time to get in for treatment because the cost will be nothing to you!

Premium: The amount you pay each month for health insurance.