If you have trouble understanding your health insurance, you’re not alone. We’ve untangled the key terms you’re likely to come across when dealing with all things health insurance.


Your health plan provides coverage to help you pay for medical care and prescriptions. A premium is the amount you pay out of each paycheck for health insurance. In return, your health plan provides coverage when you need care and helps you stay healthy.


There’s also the deductible. That’s the set amount you pay out-of-pocket each year before your health plan starts to pay. You should note that the deductible can vary across your plan options; not all plans will have a deductible.


Once you’ve hit your deductible, your co-insurance will kick in. This is the cost you’ll split with your insurer. You’ll pay a percentage of the total cost of medical services, and your insurance covers the rest. A common co-insurance split goes by the rule of 80/20, where the insurance company pays 80 percent of the total cost while the patient pays 20 percent. With that said, please check with your insurer to see what your plan covers.


Some plans will require a copayment for certain services. A copay is a set amount you’ll pay each time you visit the doctor. For example, a copay for medical services might be $20 per office visit and $30 for a prescription—it depends on your plan.

Out-of-Pocket Limit

This is the most you’ll pay out-of-pocket for services during the year. Any money you pay for in-network services towards the deductible, copayments and coinsurance counts towards your plan’s out-of-pocket limit. Once you reach that limit, you’re done paying for in-network services covered by your plan.


The plans network is made up of a group of doctors and facilities that have contracted with your insurance carrier to provide services. The amount of money you’ll pay out-of-pocket for services depends on the type of plan you’re enrolled in, and whether your doctor is in your health plan’s network. You’ll most likely pay less out-of-pocket when you use in-network providers.


Lastly, if you or your health care provider has ever asked your insurance provider to pay for medical services, then you’ve filed a claim. The insurance company then reviews the claim for validity and then pays you or your healthcare provider.

Still have questions? We’ve got more resources to help, visit https://myhealthmath.com/employee-resource-center/