Insurance Made Simple: User-Friendly Definitions

The health insurance game is complicated. ADVENT explains the insurance terms and basics you need to know before booking your appointment. Learn more.
Insurance Made Simple: FAQ's and Definitions
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Published on
July 8, 2022
Updated on
July 12, 2022

The health insurance game is complicated, especially when you're met with puzzling terminology, protocols you can't process, endless red tape and a less-than helpful call center representatives.

When it comes to addressing your sinus and sleep concerns, dealing with your insurance company and healthcare costs only adds to your hesitation. Not to worry, we're here to decipher common insurance terms and answer FAQ's so you can be the best advocate for your health.

The Insurance Advantage

We work hard to help you get the most out of your insurance. Our team is available to answer your questions pertaining to services and insurance coverage. We'll fight for procedure approvals and overturn insurance claims - if needed we'll even work with you for payment flexibility, so you can start living better today.

We've got the basic plan information and terminology if you're new to the insurance game or need a basic understanding of insurance.


Insurance Terminology


Your deductible is the amount you pay for covered services each year before your insurance starts paying. Depending on your plan, you may pay copays or coinsurance for some services without reaching your deductible.

Co-Pay (Copayment)

The amount of money you pay for each healthcare service, such as a visit to the doctor, laboratory tests, prescription medicines, and hospital stays. The amount of the copay usually depends on the type of healthcare service.

In-Network versus Out-of-Network

In-network providers, hospitals, independent practices, and pharmacies that are a part of a health insurance plan's network will typically cost less than services out of network. This cheaper, negotiated rate is due to a discount in exchange for insurance company referrals.


The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

Typically, if the percentage you're responsible for is lower, the premium is higher.

Out-of-Pocket Maximum

Your out-of-pocket maximum is the most you'll pay for covered services each year. You may need to keep paying copays or coinsurance after reaching your out-of-pocket maximum for a few services.

Individual Plan Versus Family Plan

An individual plan has one member or just one person covered by the plan. Family plans cover two or more members. Your plan's deductible and out-of-pocket maximum are based on whether you have an individual or family plan.

Find out if your insurance is in-network.

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Frequently Asked Questions:

How does insurance work once deductible is met?

Once you've met your deductible, you usually only pay a copay and/or coinsurance for covered services. Coinsurance is when your plan pays a large percentage of the cost of care and you pay the rest. For example, if your coinsurance is 80/20, you'll only pay 20 percent of the costs when you need care.

Do you have to pay coinsurance if deductible is met?

Does Coinsurance count toward the deductible? No. Coinsurance is the portion of health care costs that you pay after your spending has reached the deductible. For example, if you have a 20% coinsurance, then your insurance provider will pay for 80% of all costs above the deductible.

Is coinsurance after max out-of-pocket?

What you pay toward your plan's deductible, coinsurance and copays are all applied to your out-of-pocket max. When the deductible, coinsurance, and copays for one person reach the individual maximum, your plan then pays 100 percent of the allowed amount for that person.

What does coinsurance out-of-pocket maximum after deductible mean?

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit doesn't include your monthly premiums.

What happens if you don't meet your deductible?

Many health plans don't pay benefits until your medical bills reach a specified amount, called a deductible. If you don't meet the minimum, your insurance won't pay toward expenses subject to the deductible.

What is deductible vs out-of-pocket maximum?

In a health insurance plan, your deductible is the amount of money you need to spend out of pocket before your insurance starts paying some of your health care expenses. The out-of-pocket maximum, on the other hand, is the most you'll ever spend out of pocket in a given calendar year.

What happens when you meet your deductible and out-of-pocket?

Once you've met your deductible, your plan starts to pay its share of costs. Then, instead of paying the full cost for services, you'll usually pay a copayment or coinsurance for medical care and prescriptions. Your deductible is part of your out-of-pocket costs and counts towards meeting your yearly limit.

How does deductible, coinsurance and out-of-pocket work?

Your coinsurance kicks in after you hit your deductible. If your plan has a $100 deductible and 30% co-insurance and you use $1,000 in services, you'll pay the $100 plus 30% of the remaining $900, up to your out-of-pocket maximum.

Do you have to pay deductible upfront?

A health insurance deductible is a specified amount or capped limit you must pay first before your insurance will begin paying your medical costs. For example, if you have a $1000 deductible, you must first pay $1000 out of pocket before your insurance will cover any of the expenses from a medical visit.

Give us a call. We're here to help:

First published by ADVENT on
July 8, 2022
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Insurance Made Simple: User-Friendly Definitions