Learn the terminology and concepts that affect your healthcare costs. Use our interactive calculator to see how insurance works in practice.
Monthly or annual cost to keep your insurance active
You pay this regardless of whether you use healthcare services. Think of it as the "membership fee" for insurance coverage.
Example:
Your employer-sponsored health plan costs $450/month. This is your premium.
Amount you must pay before insurance starts covering costs
Once you've paid this amount out-of-pocket, your insurance plan begins to share costs with you. Higher deductibles mean lower premiums.
Example:
Your plan has a $1,500 deductible. You pay the full cost of healthcare until you've spent $1,500, then insurance kicks in.
Fixed amount you pay per visit or service
A flat fee (like $25 for a doctor visit) that you pay each time you receive a specific service. This applies after you meet your deductible.
Example:
Your plan has a $30 copay for specialist visits. Each time you see a cardiologist, you pay $30 (if deductible met).
Your percentage of the cost after the deductible is met
Once you've met your deductible, you and your insurance split the remaining cost. For example, you pay 20% and insurance pays 80%.
Example:
A surgery costs $10,000. Your insurance covers 80%, you pay 20% coinsurance = $2,000.
Maximum amount you'll pay in a year before insurance covers 100%
Once you've paid this amount in deductibles, copays, and coinsurance, your insurance covers the rest of covered services at 100% for the rest of the year.
Example:
Your out-of-pocket max is $5,000. After you've paid $5,000, insurance covers everything else at 100% that year.
Approved doctors, hospitals, and providers under your plan
In-network providers have negotiated rates with your insurance. Out-of-network care costs more and you may have different coverage levels.
Example:
Dr. Smith is in-network (lower cost). Dr. Jones is out-of-network (higher cost, less coverage).
Enter your insurance details and a medical bill to see how costs are calculated.
The cost of your medical service
Total you must pay before insurance starts sharing costs
How much you've already spent toward your deductible this year
Your percentage of cost after deductible (e.g., 20%)
Maximum you'll pay in a year before insurance covers 100%
You've met $500.00 of your $1,500.00 deductible. This bill will count $1,000.00 toward it. After this bill, you'll still owe $1,000.00 to meet your deductible.
After the deductible, the remaining $9,000.00 is split: you pay 20% ($1,800.00), insurance pays 80% ($7,200.00).
You're paying:
$2,800.00
for this bill
You have remaining:
$1,700.00
until you hit your out-of-pocket max
Progress to out-of-pocket max:
If your insurance denies coverage for a procedure or medication, you have the right to appeal. Here's the process:
Carefully read the denial letter from your insurance company. It should explain:
Collect evidence that supports your appeal:
Submit a formal written appeal before the deadline (usually 30-60 days). Include:
If the insurance company upholds the denial on internal appeal, you can request an external review by an independent medical reviewer. This is free and can overturn the denial.
If external review fails, you may file a complaint with your state's insurance commissioner or consider legal counsel. Many attorneys specialize in insurance claim disputes.
Official federal site for health insurance information, coverage, and rights.
Independent health insurance reviews and guidance.
Free help with insurance appeals and patient advocacy.
Government oversight of insurance regulations and appeal rights.