💰 Premium
Your monthly payment to keep your insurance active. You pay this whether you use healthcare or not. Think of it like your Netflix subscription—you pay monthly to have access.
💵 Deductible
The amount you pay out-of-pocket before your insurance starts sharing costs. For example, with a $1,500 deductible, you pay the first $1,500 of covered services yourself, then your insurance kicks in.
🤝 Coinsurance
After you meet your deductible, you and your insurance split costs. Common splits are 80/20 or 70/30. If it's 80/20, your insurance pays 80% and you pay 20% of covered services.
🏥 Copay
A fixed amount you pay for specific services, like $30 for a doctor visit or $10 for generic prescriptions. Copays usually don't count toward your deductible but do count toward your out-of-pocket max.
🛡️ Max Out-of-Pocket
The most you'll pay in a year for covered services. Once you hit this limit, your insurance pays 100% for the rest of the year. This protects you from catastrophic medical costs.
📋 Top 5 Medical Claim Terms
1. Explanation of Benefits (EOB): A statement from your insurance showing what was charged, what they paid, and what you owe. Not a bill!
2. Prior Authorization: Your doctor must get approval from insurance before certain procedures or medications are covered.
3. In-Network vs Out-of-Network: In-network providers have contracts with your insurance for lower rates. Out-of-network costs more or may not be covered.
4. Allowed Amount: The maximum your insurance will pay for a covered service. If a doctor charges more, you may pay the difference (if out-of-network).
5. Coordination of Benefits (COB): When you have two insurance plans, this determines which pays first (primary) and which pays second (secondary).
