Insurance Can Be Confusing!
Common Terms and What They Mean
All the terms for insurance can be overwhelming. Here are some definitions that may help you discuss best options.
What is a Premium?
An insurance premium is the amount of money you pay to an insurance company for coverage under an insurance policy. This payment can be made on a regular basis, such as monthly, quarterly, semi-annually, or annually. In exchange for paying the premium, the insurance company agrees to provide financial protection against specified risks, such as health issues, accidents, property damage, or death, depending on the type of insurance policy you have. The amount of the premium is determined by factors such as the type and amount of coverage, your risk profile, and any applicable discounts or credits.
What is a Deductible?
A deductible in insurance is the amount of money you must pay out of pocket before your insurance company starts to cover the remaining costs of a claim. It is a form of cost-sharing between you and the insurer. Here’s how it works:
Higher Deductible, Lower Premium: Generally, choosing a higher deductible will result in lower premium payments. Conversely, a lower deductible means higher premiums.
Claim Process: When you make a claim, you pay the deductible amount first, and then the insurance company pays the covered expenses that exceed this amount.
What is a Copayment?
A copayment, or copay, in insurance is a fixed amount that you pay out of pocket for a specific healthcare service or prescription medication at the time of service. This payment is typically required after you have met any applicable deductibles under your insurance plan. Here’s how it works:
Fixed Amount: The copay is a set fee, such as $20 for a doctor’s visit or $10 for a generic prescription, regardless of the actual cost of the service or medication.
Service-Specific: Copay amounts can vary depending on the type of service. For example, a visit to a specialist may have a higher copay than a visit to a primary care physician.
After Deductibles: In some plans, copays apply only after you have met your deductible, while in others, they apply immediately without needing to meet a deductible first.
What is the Out of Pocket Max?
The out-of-pocket maximum (OOPM) in insurance is the most you will have to pay for covered healthcare services in a plan year. Once you reach this limit, your insurance company pays 100% of the costs for covered benefits. Here’s how it works:
Includes Deductibles, Copayments, and Coinsurance: The OOPM typically includes all your out-of-pocket costs such as deductibles, copayments, and coinsurance. However, it does not include your premium payments.
Protection from High Costs: The OOPM provides a cap on your healthcare spending for the year, protecting you from excessive medical expenses in case of major health issues.
Plan Year Basis: The OOPM resets each plan year. Once the new plan year begins, you start contributing towards the OOPM again.
For example, if your plan’s OOPM is $6,000 and you have already paid $6,000 out of pocket for covered services, any further covered medical expenses for the remainder of the plan year will be fully paid by your insurance company.


