Healthcare Insurance Terms

Making Sense of Your Insurance Policy

Healthcare Insurance terms are confusing. Don’t be frustrated, because I can help. First of all, health insurers are required to provide you with an easy-to-understand summary of your benefits. This will make it simple to see what kind of coverage you have (including addiction and mental health services).  

Summary of Benefits

An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans.

You can compare options based on price, benefits, and other features that may be important to you. You’ll get the “Summary of Benefits and Coverage” (SBC) when you shop for coverage on your own or through your job, renew or change coverage, or request an SBC from the health insurance company.

Next, it’s important you understand the terms that affect how much money you must pay every month, and how much you pay when you use the insurance. Thanks to Healthline this is easy too!


Why is health insurance so confusing? Because if Americans could easily figure out how much healthcare actually costs in this country, they would freak out.

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 your pocket before your insurance will cover any of the expenses from a medical visit. It may take you several months or just one visit to reach that deductible amount.

You will pay your deductible payment directly to your medical provider. Note: your deductible automatically resets to $0 at the beginning of your policy period.


A health insurance premium is an amount you pay each month to your insurance provider. This is the only payment you will have if you never use your health insurance. You will continue to pay premiums until you no longer have the insurance plan. A deductible only has to be paid if and when you use the insurance. Note: If you receive insurance through an employer, your premium is typically deducted directly from your paycheck.

Deductible vs. Copay

Your health insurance will begin paying for your health care expenses once you meet your deductible. You may, however, still be responsible for an expense each time you use the insurance.

A copayment is the portion of a medical insurance claim that you are responsible for paying. In most cases, a doctor’s office will request the copayment at the time of your appointment. Copayments are usually fixed modest amounts. For example, you may be responsible for a $25 copay every time you see your general practitioner. This amount varies among insurance plans. In some cases, the copayment is not a set amount. Instead, you may owe a set percentage based on the amount your insurance will be charged for the visit.

Deductible vs. Out-of-Pocket Maximum

Your out-of-pocket maximum is the most you will pay during a policy period. Most policy periods are one year-long. Once you reach your out-of-pocket maximum, your insurance plan will pay all additional expenses at 100 percent.

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Treatment for drug abuse and addiction is delivered in many different settings, using a variety of behavioral and pharmacological approaches.

Note:  The out-of-pocket maximum is typically rather high, and it varies from plan to plan.

High- vs. Low-Deductible Plans

High-deductible, low-premium insurance plans have gained popularity in recent years. These insurance plans allow you to pay a small amount each month in premium payments. Your expenses when you use your insurance, however, are often higher than a person with a low-deductible plan. A person with a low-deductible plan, on the other hand, will likely have a higher premium but a lower deductible.

High-deductible insurance plans work well for people who anticipate very few medical expenses. You may pay less money by having low premiums and a deductible you rarely need. Low-deductible plans are good for people with chronic conditions or families who anticipate the need for several trips to the doctor each year. This keeps your up-front costs lower so you can manage your expenses more easily.

What’s the Right Deductible for Me?

A high-deductible plan is great for people who rarely visit the doctor and would like to limit their monthly expenses. If you choose a high-deductible plan, you should be good at saving money so that you are prepared to pay any medical expenses up front.

A low-deductible plan may be best for a larger family who knows they will be frequently visiting doctors’ offices. These plans are also a good option for a person with a chronic medical condition. Planned visits such as well visits, check-ups on chronic conditions, or anticipated emergency needs can quickly add up if you are on a high-deductible plan. A low-deductible plan lets you better manage your out-of-pocket expenses.

Decide which type of plan — HMO, PPO, EPO, or POS — is best for you and your family.

Talk with Your Insurance Provider

If you are trying to pick the right insurance for you, visit with a local health insurance provider or Enrollment might be closed (it depends on the time of year). However, you can get covered if you have certain life events — like getting married, having a baby, losing other income, or moving.

If you are uninsured do something about it. As of last year, most individual and small group health insurance plans, are required to cover drug addiction treatment. This includes alcoholism and mental illness.

Drug Addiction Treatment and Insurance

This might blow your mind. Addiction Treatment might be owed to you under certain laws. There are also other protections for you under the American with Disability Act.

I suggest to give us a call. If you call your insurance company they may try and give you a treatment program that is not ideal for you. We know of many available options and can even fight to have your deductible waived.

If you don’t any insurance or resources head over to our sister site No Cost Rehab. We have some options for you no matter what your circumstance.