Deductible is what you need to pay out of pocket on your own before the insurance plan starts covering you for future visits. You can either pay out of pocket and have the office bill your insurance towards that deductible or you can pay it out right through your insurance. Once your deductible is satisfied your insurance will start covering services either in full or at a cost to you that isn't full price. Considering there's a bunch of different plans your "copay" (the cost which your insurance charges you now that you've satisfied the deductible) applies and you just pay that small amount for the visit of what ever medical service you go to.

Now to go into what your plan premiums are, in layman terms that's your monthly fee to keep your plan active, while also having a deductible to pay so you can access medical services you need

Copay is your cost for each visit. Depends on the service. It might be $20 to see your doctor. $40 for a specialist. $300 if you’re admitted to the hospital.

Deductible is the amount you have to pay before insurance kicks in. Say yours is $1500. In some plans that’s for medical services beyond visits. So seeing the doctor my cost you $20 as a copay and insurance pays the rest. Now you need an X-ray which is $300. You have to pay that and that counts as part of your deductible. Now they send you for an MRI that’s $4000. The first $1200 is on you (the rest of your deductible), then the insurance covers the rest.

Lots of fine print. Some plans pay everything past the deductible. Some pay 80% of that and you still pay 20%.

In some plans the deductible only applies for stuff like X-rays, MRIs, and surgeries. Other plans it may apply to other basic visits.

Your health insurance has doctors and clinics that they have a contract with that covers rates. These are in network and normally a lot cheaper for you. If you go to a different doctor not on their list, it’s considered out of network which means at least two worse things. One is lower coverage, and the other is insurance only covers at their “normal” rate. Say you see an allergist, and their bill is $200. Insurance says “we cover 80% of our standard rate. Our standard rate is $150 so we may $120” So you end up owing 80 to the allergist.

If you have a genuine emergency while traveling (eg chest pain) on a decent plan you can get emergency service even at an out of network hospital but you may have to call first.

Yeah, it's all confusing. The easiest way to think about it is there are limits that apply to your *total spend* per year, and there are limits that apply to your *per visit* spend.

Deductible and out-of-pocket max apply to your total spend per year.

Co-pay and Co-insurance apply to your per visit (and by visit, I mean any individual service, such as doctor visit, hospital stay, surgery, pharmacy medication fills, etc).

Let's start with the total spend terms.

Deductible: This is the amount of total spend you need before the insurance company kicks in a single dollar. So, for example, if you have a $1000 deductible, then you will have to cover the first $1000 of your total spend, before the insurance company starts covering anything.

Out-of-pocket max: This is the amount of total spend you need before the insurance company starts covering 100% of your costs. So, for example, if you have a max out-of-pocket of $5000, then after your total spend for the year hits $5000, everything after that will be covered by insurance.

So what happens between those 2 numbers, $1000-$5000? That's where the per-visit charges apply.

Co-pay: a *set* amount you pay for the visit. So for example, a doctor's visit may have a copay of $50. A hospital visit may have a copay of $500. And a medication may have a copay of $5. That means that regardless of the actual cost of those things, you will pay the copay. Let's say one hospital visit costs $1000, and one hospital visit costs $5000. Doesn't matter. Either way, you pay the $500 copay and the insurance company picks up the rest.

Co-insurance: a *percentage* amount you pay for the visit. Let's say you have a co-insurance of 20% for hospital visits. In this scenario, if a hospital bill was for $1000, then you would pay $200 (20%), and if it was $5000 then you would pay $1000 (again, 20%).

So basically, on January 1st, all the numbers rest. From there, let's say you have a few doctors visits and a couple of medications. Since you haven't "met the deductible" yet, you will pay 100% of the cost of those services, until you've spent $1000.

Then, once you've paid $1000 out of your pocket, the copays and co-insurance start applying. So at that point, any further doctor visits, you would pay the copay/co-insurance. Any hospital stays, medications, etc., same thing. You would be responsible only for the copay/co-insurance -- after you've met the deductible.

All these copays and co-insurances start adding up, and at some point, you will have paid $5000 out of pocket. At that point, the out-of-pocket max threshold is hit, and from then on, insurance will cover 100% of your expenses.

Does that make sense?

Finally, regarding in-network and out-of-network. Most insurance plans have negotiated discounts / preferred prices with specific doctors and hospitals. These will be considered in-network (they are part of the insurance company's network of "preferred providers" because they have set, negotiated rates with the insurance company). Doctors and hospitals that don't have a contract with the insurance company are technically allowed to charge you whatever they like, since they haven't negotiated any set pricing with your insurance company. These are considered out-of-network providers.

Insurance companies will have different deductibles, copays, co-insurance, max out-of-pocket, etc. for in-network vs out-of-network providers. Generally speaking, the numbers will be set lower (i.e. lower cost to you) for in-network providers, mainly as a way to incentivize you to see in-network providers, since they're generally cheaper for the insurance company (since they've negotiated their rates and signed a contract). Some insurance plans, such as HMOs will have *zero* coverage for out-of-network providers, to basically force you to stay in-network, in exchange for a lower premium or lower out-of-pocket costs. And others (Generally more expensive) will have better coverage for out-of-network providers.

Different insurance companies will have different doctors/hospitals in their network, based on who they've negotiated with. So for example, Insurance A might have doctor B and hospital C in their network, while Insurance D might have doctor E and hospital F in-network, while Insurance C might have all of them in-network.

My recommendation on how to shop for insurance is to first determine what services you will need. If you already have doctors that you see and you want to keep seeing them, make sure that they are in-network. That will generally give you the lowest out-of-pocket costs to see them. And don't forget the unexpected stuff. You may not need regular hospital care, but maybe you really want to make sure the local University hospital is covered in case you ever need specialized care. If an insurance company's only in-network hospital is 50 miles away from you (not uncommon if you don't live in a big city) while the hospital 5 minutes away from you is out-of-network, make sure you know that before signing up.

Next, determine how important out-of-network coverage is for you. If you want the freedom to be able to go to anyone you want, or any hospital you want, then you'll want to pay extra to get good out-of-network coverage.

Finally, look at the cost of the various plans, and, once you have all of the above info about the different plans, hopefully you'll be able to choose one that contains the right balance of in-network and out-of-network costs, with the best set of in-network providers (based on who you want to get care from), for the best price. That's a difficult juggling act, but if you first gather all of the information, you'll have a better shot at making the right decision.

Good luck!

PS insurance companies make it somewhat difficult to find out who is in-network and who is out-of-network. One common tactic is to say "Oh, we at Blue Cross contract with a thousand physicians!" That may be true, but each insurance company sells dozens of different insurance plans. And the network for each plan is *not* the same. So you have to make sure you check the network not for the company as a whole, but for the specific plan you're checking out.

• Premium: The monthly fee you pay to the insurance company.

• Deductible: The amount you have to pay for a good or service before your insurance kicks in and covers the rest of your cost.

• Copayment: Also abbreviated as copay, this is the flat rate you pay for a good or service that's covered by your insurance.

• Coinsurance: This is when you still have to pay some of the costs above the deductible, usually a percentage value.

• Out-of-pocket maximum: If your combined payment for deductibles, copay, and coinsurance goes above this amount within a year, everything above that is paid by your insurance company.

Let's go with an example to illustrate how these all interact. You have an insurance plan with a $2,000 deductible, 20% coinsurance, $100 copay for a doctor's visit, and an out-of-pocket maximum for $4000. You get into an accident that requires surgery; the hospital bills your insurance company for $10,000. This means you've gotta pay $2,000 to cover your deductible. Of the remaining $8,000, also you have to pay 20%, or $1,600, as coinsurance. You have five followup appointments with the doctor to see how you're recovering. You pay your $100 copay for the first four appointments, but the fifth appointment doesn't require a copay, because it's above your out-of-pocket maximum.

Now, there are plans out there that have lower deductibles, copays, coinsurance, and/or out-of-pocket maximums, but those usually have the tradeoff of charging a higher monthly premium. Some insurers also have special deals with medical providers where they get better rates; you get full benefits if you use those providers ("in-network"), but you only get partial or no benefits if you use others outside the network.

Most insurance is provided by one's company, usually with a discounted premium. The US government also has several insurance programs: Medicare for the elderly, Medicaid for those below the poverty line, VA benefits for veterans.

Putting this here since it’s not allowed to be a top-level comment, but I found this YouTube video to also be helpful in explaining these common US medical insurance terms. The system definitely presented as something that should be changed, but I found the information given as helpful.

https://youtu.be/-wpHszfnJns

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This was a huge help. I'm starting a job as office manager of an endodontist office and I'm mostly worried about all the insurance stuff, knowing how kuch to charge people, etc