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Understanding Common Health Insurance and Medicare Terms

Navigating the world of health insurance and Medicare can be confusing. Working with a licensed insurance agent can help you navigate the terminology and understand the best options that are available to you. Here’s a quick guide to some of the most common terms you may encounter.



The premium is the amount you pay for your health insurance plan, typically monthly. This fee is separate from other potential costs like deductibles and copayments.



A deductible is the amount you must pay out-of-pocket for healthcare services before your insurance kicks in. For instance, if your deductible is $1,000, you'll need to cover the first $1,000 of your medical expenses.


Copayment (Copay)

A copayment is a fixed amount you pay for a specific service or prescription medication at the time of the service. For example, you might have a $20 copay for a doctor's visit.



Coinsurance is your share of the costs of a covered service, calculated as a percentage. For instance, if you have 80/20 coinsurance, your insurance covers 80% of the service cost, and you're responsible for the remaining 20%.


Out-of-Pocket Maximum

The out-of-pocket maximum is the most you will pay during a policy period (usually a year) before your insurance covers 100% of the allowed amount. This includes costs like deductibles, copayments, and coinsurance.



A network is a group of doctors, hospitals, and other healthcare providers that have agreed to provide services to the insurance company's members at discounted rates.

- In-network providers are part of the network.

- Out-of-network providers are not part of the network and generally cost more.


Prior Authorization

Prior authorization is a requirement that your healthcare provider obtains approval from your insurance before providing a service or prescribing a medication. This ensures that the service or drug is medically necessary.



Medigap is supplemental insurance sold by private companies to cover some of the costs not covered by Original Medicare, such as copayments, coinsurance, and deductibles.


Understanding these terms can empower you to make better decisions regarding your healthcare coverage, ensuring you receive the care you need without unnecessary financial surprises.


Always review your plan details, and don’t hesitate to ask your licensed insurance agent or provider for explanations if needed.


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