Until working in this field, I was entirely guilty of not understanding my health insurance; but it seemed so basic! When I got into the workforce for the first time, a few friends and I sat down and reviewed our benefits with each other. Everyone around me understood what everything was/what everything meant, so I just played along and acted as if I understood mine, too. 

This, coming from a person who is not afraid to ask for help, makes me assume there are more of you out there. Maybe your partner handles insurances or finances, maybe they're the policy holder and you're classified as a dependent on their insurance. Whatever the reason, I'm just going to explain the difference between a few things some of our patients tend to get mixed up, or confused over. 

First things first: Coverage Types 

Most of the time, you're looking at two different sections: medical and dental. Under medical lies anything you can imagine; ranging from doctor's visits, to physical therapy, to maternity, to mental health. Dental will include all aspects of dental, including regular teeth cleanings, orthodontists, oral surgery, etc. 

Next: Your Insurance Card

Your insurance card carries all the information you need to get details regarding your benefits and coverage. On the back (maybe even the front) of the card, there will be a customer service line. It may have two, one being for providers. That line is meant for the doctor's office, only. You call the regular customer service line. 

  • You'll need to know your name, date of birth, and the member ID number. That's usually found on the front of your card.
  • From there, you'll be asked whether you want coverage or benefits. If you've recently activated your health insurance, or are curious as to when your plan expires or begins, you want coverage. If you want detailed information regarding your specific plan, you want benefits

Benefits will give you your copay's, out-of-pockets, deductibles, etc.  Many systems are automated now-a-day, so ask to "speak to a representative" and the system should transfer you to an actual person who can help. 

Copay, Deductibles, and Out-of-Pockets

Copay: A flat-rate payment you make each time for a specific medical service - not everyone has one in their plan
Example: Paying $25 dollars each time you go in to see your doctor for updated prescriptions, or each time you go in for physical therapy. It can range from $10 for an office visit to in the hundreds for things like an emergency room visit. It is due every time at the start of your appointment. May or may not be applicable to your deductible, but is always applicable to your out-of-pocket maximum.

Deductible: A defined amount of money the policyholder must meet in order to receive insurance coverage AT ALL. 
Example: This is usually a number somewhere in the middle, ranging anywhere from $100 to $5-6,000. You will need to meet your deductible in it's entirety before any insurance coverage will kick in. 

Out-of-pocket Maximum: Defined amount of money the policyholder must meet in order to receive full coverage by their insurance (the insurance company pays 100% of the medical bill). 
Example: This is usually a much higher number, anywhere from $500 to $10,000. Your insurance coverage while you work to meet your out-of-pocket maximum can range anywhere from 60/40 to 100% coverage. 

These three will re-start each year, either associated with the calendar year, or the policy year. The policy year is simply a year from which your coverage began. They are applicable to all types of coverage under that type-umbrella, so all types of medical or all types of dental; meaning, your deductible for your medical coverage is different than your deductible for your dental coverage.