Navigating insurance can be confusing so here are some definitions of commonly-used language to help you make sense of it.

Deductible

This is the amount you owe before your benefits start kicking in. For example, if your deductible is $1,500, your plan will not provide coverage until you’ve paid your $1,500 deductible. 

Copay

This is what you pay each time you see your provider. It may vary according to the service you are receiving. For example, you might pay a $30 copay to see your dietitian and a $25 copay to see your therapist. Your copay is also a fixed amount no matter the duration of your service. For example, you see your dietitian for a 90-minute intake one week and a 55-minute session the following week. For both appointments, you would pay the same copay amount.

Co-insurance

This is what you pay each time you see your provider, but unlike a copay that is a fixed amount, it is a percentage of the rate. For example, if the rate is $200, and your co-insurance is 10%, you would pay $20, and your insurance would cover the rest. 

Out-of-Pocket

Sometimes called Out-of-Pocket Max or Out-of-Pocket Limit, this is the maximum amount you will pay in healthcare costs before your insurance provider will cover all healthcare expenses. For example, your Out-Of-Pocket is $4,000 and your deductible is $2,000. After paying your deductible, and an additional $2,000 of copays, co-insurances and other healthcare expenses, your insurance will cover healthcare costs moving forward. It will be important to report all expenses to your insurance company so they can count it towards your Out-of-Pocket. 

Primary and Secondary Insurance

Most people have one insurance provider, but some people have two. When this happens, one insurance company is assigned the primary and the other is assigned the secondary. You must inform each insurance about the other so your claims may be processed correctly. First, your claims will be sent to the primary for processing. If your primary insurance plan covers your service, then the process is complete. If your primary insurance does not offer coverage, or only partial coverage, your secondary insurance will cover the rest. 

Please note that deductibles, copays and co-insurances are determined by the insurance provider, not the healthcare provider. Healthcare providers are not able to negotiate these fees and must collect them, as required by the insurance companies.

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