Insurance Made Simple

Your Guide to Insurance Lingo & Frequently Asked Questions

The health insurance game is complicated, especially when you’re met with puzzling terminology, protocols that don’t make sense, endless red tape and less-than-helpful call center representatives.

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

It’s your insurance, so of course we want to help you get the most out of it. That’s why we have a team dedicated to helping you understand how your insurance plan works and will answer any questions you might have. Plus, we’ve got your back…we’ll fight for any procedure approvals and help overturn insurance claims if necessary. We’ll even work with you for payment flexibility, so you can start living better today.

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Insurance Terminology

If you're new to the insurance game or need a refresher in understanding of insurance, here’s the skinny on basic insurance plan information and terminology:

Deductible

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.

Coinsurance

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.

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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.

Tip: If you’re going to hit your out-of-pocket maximum, it’s better to do it earlier in the year…that way you don’t have to worry about it for the rest of the year’s healthcare costs.

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 is based on whether you have an individual or family plan.

Insurance FAQs

Answers to FAQs so you can be the best advocate for your health.

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.

Do you have to pay the 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.

How do 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.

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.

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 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.

Do you have to pay coinsurance if the 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.

How does insurance work once the 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.

Still Have Questions?

While the world of insurance may be overwhelming, know that we’re here to help guide you through the process. Don’t let insurance complexity keep you from putting your sinus and sleep concerns to bed for good.

Give us a call. We're here to help: 888.938.3838

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