Health insurance is hard enough. Let our guide simplify some common health insurance terms. If you’re company has an open enrollment or annual benefits election, now is the time to understand these health literacy terms so you can make the best healthcare decisions for you and your family.

What is a deductible?

Simply put, a deductible is the amount you have to pay before your health plan starts to share the cost of healthcare services you receive. For example, if you have a $1,500 deductible, you pay the first $1,500 for covered healthcare services. Once you’ve paid your deductible, you’ll only pay a fixed amount (like copays or coinsurance).

High deductible plans
Plans with a lower monthly cost generally have a higher deductible, which means you’ll pay more for healthcare services at first. This can be a good option if you’re young, healthy, and don’t make frequent trips to the doctor. If you choose this type of plan, make sure your budget can handle your plan’s higher deductible in the case of an unexpected illness or event.

Low deductible plans
Low deductible plans generally have a higher monthly cost, which means you’ll have lower out-of-pocket costs whenever you do go to the doctor or order a prescription. This might be the right choice for you if you have a chronic health condition that needs frequent treatment, you have unique medical conditions, or you are prone to high-risk sports injuries. Or, you may just be willing to pay more every month to reach your deductible more quickly.

Where does the word ‘premium’ come in?
Your premium payment is the amount that you pay to have insurance—it’s like a membership fee to your health plan. It’s usually paid on a monthly basis. Your monthly premium does not count towards your deductible, nor do copays. You’ll still be responsible for these expenses after you reach your deductible.

What’s the difference between aggregate and embedded deductibles? 
The difference comes down to whether there’s more than one person on your health plan. If there is more than one person, you can either share a deductible or have your own individual deductibles. 
When it’s a shared deductible, also known as aggregate, the healthcare costs of each person contribute to the total.
 
When it’s an individual deductible, also known as embedded, only the costs each individual person racks up count towards their own deductible.
 
An aggregate deductible is usually higher since it covers more people, but it’s also faster to reach since more costs contribute towards it.

Is there anything covered before I reach my deductible? 
Certain healthcare costs, especially preventive care, are usually covered whether or not you’ve reached your deductible.
 
Also, it’s not that your health plan isn’t covering costs before you reach your deductible. Any in-network cost reflects a rate that your health plan has negotiated on your behalf, which is lower than the amount you would pay otherwise, saving you money even before you meet your deductible.

What is a premium?

A premium is the amount you pay for your health insurance—it’s basically your monthly membership fee for having a health plan. The exact amount of your premium depends on your health plan. Some plans have a higher premium, while others have a lower premium.

How often do I pay a premium?
Typically, you pay your premium monthly. If you have insurance through your employer, your payment is taken out of your paycheck automatically—before taxes, which saves you some money. But, if you purchase a health plan for yourself, you’ll need to make these payments on your own.

If I pay a premium, does this mean all medical expenses are covered?
Unfortunately, no—you’re still responsible for other expenses, like deductibles, co-pays, and coinsurance. Your premium is a routine payment that keeps your coverage active—it’s not something that means everything else is now $0. 

How do I know what premium is right for me?
A lot of it comes down to personal preference and your individual healthcare needs. While the plan with the lowest monthly premium may seem like a better option, it’s important to consider how often you go to the doctor. If you go frequently, you may want to consider a plan with a higher premium but a lower deductible, which can save you money in the long run. 

One advantage of a high-deductible plan—which usually comes with a lower premium—is that they let you pay out-of-pocket expenses through a health savings account (HSA). A health savings account is a tax-exempt account (extra bonus!) that you can use to pay for qualified medical expenses until your deductible is met.

How can I find out the cost of my premium?
You can usually locate the price on your health plan website or on printed marketing materials. It can also be found in your pay stub or paycheck.

Is it possible to lower my premium?
You can switch to another plan for a lower premium, but that might mean less benefits or a smaller provider network. Basically, a different premium means a different health plan.

What is coinsurance?

You’re about to choose a health plan but you realize there’s a word you’re not familiar with —coinsurance. What is that exactly? Well, it’s the percentage that you owe toward certain healthcare services, typically after you’ve met your deductible. Still confused? An example might help.
Let’s say you get a $200 bill for an in-network visit but you’ve met your deductible. You would only be responsible for coinsurance, which happens to be 10% of the $200 or $20. Your health plan is responsible for the other 90% or $180.

Plus, your coinsurance counts toward your out-of-pocket maximum.

What is an out-of-pocket maximum?
This is the max amount you’ll have to pay for covered healthcare services in a year. After you spend this amount—on deductibles, copayments, and coinsurance—your health plan then pays 100% of the costs of in-network care. 
Remember: while you may have met your deductible, you may still be responsible for paying  coinsurance until you meet your out-of-pocket maximum.

If I see a doctor that’s out-of-network, does that affect my coinsurance?
Yes, it will. Your out-of-network coinsurance amount will always be different from your in-network coinsurance amount. If you visit an out-of-network doctor, your coinsurance amount will usually be significantly higher than if you visit an in-network doctor.
 
Is there a difference between copay and coinsurance?
Yep! Your copay is a flat fee you pay when you visit an in-network doctor, while your coinsurance is a percentage of the overall cost of a service. Co-pays won’t change as long as it’s the same type of service, but coinsurance will change depending on the doctor or office you visit.

Is coinsurance similar to additional coverage?
Nope, it’s part of your health plan. Coinsurance is not a separate insurance policy where someone may have primary or secondary insurance coverage.

What is an FSA?

A Flexible Spending Account (FSA) is a way for you to pay for many out-of-pocket medical expenses with tax-free dollars.

Just like a bank account, you open a spending account which has a debit card connected to it that you can use for healthcare services. But instead of a bank controlling it, your FSA account is managed by your employer or a vendor that your employer assigns to manage the account. All in all, an FSA lowers your taxable income and helps you save money in the long run.

What can I use my FSA for?
As your FSA grows from your monthly contributions, you can use it to pay for healthcare services, including copayments and coinsurance. In addition, you can use your FSA on prescription medications, crutches, bandages, contact lenses, hearing aids, X-rays, face masks, and more. One of the few things you can’t use your FSA toward is your monthly health plan premium.

How do I add money into my FSA?
You add money directly from your paycheck—up to a limit set by your employer. But, if you’re married, your spouse can put aside tax-free funds up to the annual contribution limit determined by their employer. It’s even possible for employers to contribute to your FSA, but they’re not required to. If your employer does contribute, the amount they contribute won’t reduce the amount you’re allowed to contribute within a plan year.

Can I use the money from my FSA anytime?
You sure can! You have the freedom and option to use the funds from your FSA for any eligible healthcare services you want. However, you have to use all of the funds in your FSA within a plan year, otherwise you’ll likely lose any money left over in your FSA. That’s why it’s important to plan ahead and not put more money in your FSA than you think you’ll spend within a year.

Is there a limit on how much I can contribute?
The IRS limits how much can be contributed to an FSA each year. For example, for FSA accounts that are used for medical expenses, the annual contribution limit per employee is $3,050 for 2023.
 
What is the difference between an FSA and an HSA?
While both accounts help you save for qualified medical expenses, an FSA account generally has a lower limit of how much you’re allowed to contribute. An FSA also will not let you carry money over to the next year. With an FSA, you may get access to your FSA money earlier in the year than an HSA account. For example, FSA funds are available to spend in their entirety at the beginning of the plan year; however, with an HSA, funds accumulate only as you contribute. Also, you must be enrolled in an FSA plan through your employer; it is an employee benefit that anyone can contribute to as long as you’re eligible. An HSA plan, on the other hand, is determined by your health insurance and you must be enrolled in a High Deductible Health Plan to get access to it.

What is an HSA?

A Health Savings Account (HSA) is a type of personal savings account that lets you set aside money before taxes to pay for healthcare costs, which can mean paying less overall for healthcare services.

Just like a bank account, you open a spending account which has a debit card connected to it that you can use for healthcare services. But instead of a bank controlling it, your HSA account is managed by your employer or a vendor that your employer assigns to manage the account.

What can I use my HSA for?
You can use it to pay for qualified, out-of-pocket medical costs like ER visits, doctor appointments, prescription drugs, therapy, and more. You can also use your HSA to pay for deductibles, copayments, coinsurance, and a handful of other qualifying expenses. Generally, you cannot use it to pay insurance premiums; however, if you’re signed up for a High Deductible Health Plan (a health plan that only covers preventive services before the deductible is fully paid), your monthly premium will typically be lower.

How do I add money into my HSA?
You can contribute to your HSA via payroll at your company, which can reduce your taxable income. Your employer may also make an initial contribution to your HSA when you’re signing up for it.

Can I use the money from my HSA anytime?
Yes, you can. HSA funds roll over year to year if you don’t spend all of the funds. However, you can only contribute to an HSA if you’re signed up for a High Deductible Health Plan. Also, once you begin any Medicare coverage, you will no longer be able to contribute to your account. However, you can continue to use your HSA funds to pay for qualified medical expenses on a tax-free basis.

How do I open an HSA?
If you’re signed up for a High Deductible Health Plan, you may be able to sign up for an HSA through your health insurance company. But, not all health insurance companies offer HSA accounts.
 
What are other benefits of an HSA?
You pay no federal income tax—which means you aren’t taxed on money you put into it, or on interest earned. This is called a triple tax advantage—any contributions, interest, investment gains, and withdrawals for qualified healthcare expenses are all federal tax-free. You also don’t need to worry about paying tax on withdrawals for qualified medical expenses, like doctor visits and more. Another benefit is that you can use your HSA to pay for qualified medical expenses for your spouse or dependents, even if they’re not on your High Deductible Health Plan. You can also invest the money in your HRA, so that it earns interest and can potentially grow over the long term. Some people invest all of the funds in their HSA or only a portion. And finally, unlike a Flexible Spending Account, you own your HSA account and can hold onto it even if you leave your employer.

What is an out-of-pocket maximum?

An out-of-pocket maximum, or out-of-pocket limit, is the amount of money you’ll pay before your health plan pays for all of your in-network healthcare costs. In other words, it’s the maximum amount you’ll spend in any given year for healthcare. Once you reach your out-of-pocket max, things like copayments and coinsurance for in-network doctors will be completely covered by your health plan.

Will I ever exceed the out-of-pocket maximum?
When it comes to in-network healthcare—nope, you won’t. The actual amount of your out-of-pocket maximum will vary depending on your plan, but you will never exceed your plan’s out-of-pocket max. In fact, that’s controlled by federal law.

What isn’t included in my out-of-pocket maximum?
Your out-of-pocket maximum does not include monthly premiums, out-of-network care and services, expenses that aren’t covered by your healthcare plan, or any costs above the allowed amount for a service that a provider might charge. That’s why it’s always a good idea to choose in-network care when possible.

Does an out-of-pocket maximum affect me before I reach it?
For sure. You should check out the out-of-pocket max before enrolling in a health plan. Once you know, it  can help you plan for your future services and help you avoid any major financial setbacks.

Can I choose my out-of-pocket maximum?
While you can’t actually choose the amount when enrolling, you’ll often have the option of selecting between plans with different out-of-pocket maxes. You might be thinking, “why wouldn’t I just choose the plan with the lowest out-of-pocket max?” This is because plans with a lower out-of-pocket maximum generally have a higher premium, while plans with a higher out-of-pocket maximum generally have a lower premium cost. So basically, you typically pay more monthly to reach your out-of-pocket max earlier.

How is an out-of-pocket maximum different from a deductible?
A deductible is the amount of money you have to pay for covered services before your insurance begins to pay for a portion. An out-of-pocket maximum is the amount of money you have you have to pay before your insurance pays for 100% of covered services. The good news is that, as you contribute to your deductible, you’re also contributing to your out-of-pocket maximum.

How can Included Health help?
If you still have questions about how your health benefits, Included Health can help. Our benefits experts can talk with you about your unique needs and solve any healthcare question you might have, from billing questions to finding out what’s covered with your plan. You can also connect with our experts to make sure you’re not overpaying for care and find more ways to save. Included Health is available for select Health Plans and Employers.

Health insurance is hard enough. Let our guide simplify some common health insurance terms. If you’re company has an open enrollment or annual benefits election, now is the time to understand these health literacy terms so you can make the best healthcare decisions for you and your family.

Some common health literacy questions:

• What is a deductible?
• What is a premium?
• What is coinsurance?
• What is an FSA?
• What is an HSA?
• What is an out-of-pocket-max?

What is a deductible?

Simply put, a deductible is the amount you have to pay before your health plan starts to share the cost of healthcare services you receive. For example, if you have a $1,500 deductible, you pay the first $1,500 for covered healthcare services. Once you’ve paid your deductible, you’ll only pay a fixed amount (like copays or coinsurance).

High deductible plans
Plans with a lower monthly cost generally have a higher deductible, which means you’ll pay more for healthcare services at first. This can be a good option if you’re young, healthy, and don’t make frequent trips to the doctor. If you choose this type of plan, make sure your budget can handle your plan’s higher deductible in the case of an unexpected illness or event.

Low deductible plans
Low deductible plans generally have a higher monthly cost, which means you’ll have lower out-of-pocket costs whenever you do go to the doctor or order a prescription. This might be the right choice for you if you have a chronic health condition that needs frequent treatment, you have unique medical conditions, or you are prone to high-risk sports injuries. Or, you may just be willing to pay more every month to reach your deductible more quickly.

Where does the word ‘premium’ come in?
Your premium payment is the amount that you pay to have insurance—it’s like a membership fee to your health plan. It’s usually paid on a monthly basis. Your monthly premium does not count towards your deductible, nor do copays. You’ll still be responsible for these expenses after you reach your deductible.

What’s the difference between aggregate and embedded deductibles? 
The difference comes down to whether there’s more than one person on your health plan. If there is more than one person, you can either share a deductible or have your own individual deductibles. 
When it’s a shared deductible, also known as aggregate, the healthcare costs of each person contribute to the total.
 
When it’s an individual deductible, also known as embedded, only the costs each individual person racks up count towards their own deductible.
 
An aggregate deductible is usually higher since it covers more people, but it’s also faster to reach since more costs contribute towards it.

Is there anything covered before I reach my deductible? 
Certain healthcare costs, especially preventive care, are usually covered whether or not you’ve reached your deductible.
 
Also, it’s not that your health plan isn’t covering costs before you reach your deductible. Any in-network cost reflects a rate that your health plan has negotiated on your behalf, which is lower than the amount you would pay otherwise, saving you money even before you meet your deductible.

What is a premium?

A premium is the amount you pay for your health insurance—it’s basically your monthly membership fee for having a health plan. The exact amount of your premium depends on your health plan. Some plans have a higher premium, while others have a lower premium.

How often do I pay a premium?
Typically, you pay your premium monthly. If you have insurance through your employer, your payment is taken out of your paycheck automatically—before taxes, which saves you some money. But, if you purchase a health plan for yourself, you’ll need to make these payments on your own.

If I pay a premium, does this mean all medical expenses are covered?
Unfortunately, no—you’re still responsible for other expenses, like deductibles, co-pays, and coinsurance. Your premium is a routine payment that keeps your coverage active—it’s not something that means everything else is now $0. 

How do I know what premium is right for me?
A lot of it comes down to personal preference and your individual healthcare needs. While the plan with the lowest monthly premium may seem like a better option, it’s important to consider how often you go to the doctor. If you go frequently, you may want to consider a plan with a higher premium but a lower deductible, which can save you money in the long run. 

One advantage of a high-deductible plan—which usually comes with a lower premium—is that they let you pay out-of-pocket expenses through a health savings account (HSA). A health savings account is a tax-exempt account (extra bonus!) that you can use to pay for qualified medical expenses until your deductible is met.

How can I find out the cost of my premium?
You can usually locate the price on your health plan website or on printed marketing materials. It can also be found in your pay stub or paycheck.

Is it possible to lower my premium?
You can switch to another plan for a lower premium, but that might mean less benefits or a smaller provider network. Basically, a different premium means a different health plan.

What is coinsurance?

You’re about to choose a health plan but you realize there’s a word you’re not familiar with —coinsurance. What is that exactly? Well, it’s the percentage that you owe toward certain healthcare services, typically after you’ve met your deductible. Still confused? An example might help.
Let’s say you get a $200 bill for an in-network visit but you’ve met your deductible. You would only be responsible for coinsurance, which happens to be 10% of the $200 or $20. Your health plan is responsible for the other 90% or $180.

Plus, your coinsurance counts toward your out-of-pocket maximum.

What is an out-of-pocket maximum?
This is the max amount you’ll have to pay for covered healthcare services in a year. After you spend this amount—on deductibles, copayments, and coinsurance—your health plan then pays 100% of the costs of in-network care. 
Remember: while you may have met your deductible, you may still be responsible for paying  coinsurance until you meet your out-of-pocket maximum.

If I see a doctor that’s out-of-network, does that affect my coinsurance?
Yes, it will. Your out-of-network coinsurance amount will always be different from your in-network coinsurance amount. If you visit an out-of-network doctor, your coinsurance amount will usually be significantly higher than if you visit an in-network doctor.
 
Is there a difference between copay and coinsurance?
Yep! Your copay is a flat fee you pay when you visit an in-network doctor, while your coinsurance is a percentage of the overall cost of a service. Co-pays won’t change as long as it’s the same type of service, but coinsurance will change depending on the doctor or office you visit.

Is coinsurance similar to additional coverage?
Nope, it’s part of your health plan. Coinsurance is not a separate insurance policy where someone may have primary or secondary insurance coverage.

What is an FSA?

A Flexible Spending Account (FSA) is a way for you to pay for many out-of-pocket medical expenses with tax-free dollars.

Just like a bank account, you open a spending account which has a debit card connected to it that you can use for healthcare services. But instead of a bank controlling it, your FSA account is managed by your employer or a vendor that your employer assigns to manage the account. All in all, an FSA lowers your taxable income and helps you save money in the long run.

What can I use my FSA for?
As your FSA grows from your monthly contributions, you can use it to pay for healthcare services, including copayments and coinsurance. In addition, you can use your FSA on prescription medications, crutches, bandages, contact lenses, hearing aids, X-rays, face masks, and more. One of the few things you can’t use your FSA toward is your monthly health plan premium.

How do I add money into my FSA?
You add money directly from your paycheck—up to a limit set by your employer. But, if you’re married, your spouse can put aside tax-free funds up to the annual contribution limit determined by their employer. It’s even possible for employers to contribute to your FSA, but they’re not required to. If your employer does contribute, the amount they contribute won’t reduce the amount you’re allowed to contribute within a plan year.

Can I use the money from my FSA anytime?
You sure can! You have the freedom and option to use the funds from your FSA for any eligible healthcare services you want. However, you have to use all of the funds in your FSA within a plan year, otherwise you’ll likely lose any money left over in your FSA. That’s why it’s important to plan ahead and not put more money in your FSA than you think you’ll spend within a year.

Is there a limit on how much I can contribute?
The IRS limits how much can be contributed to an FSA each year. For example, for FSA accounts that are used for medical expenses, the annual contribution limit per employee is $3,050 for 2023.
 
What is the difference between an FSA and an HSA?
While both accounts help you save for qualified medical expenses, an FSA account generally has a lower limit of how much you’re allowed to contribute. An FSA also will not let you carry money over to the next year. With an FSA, you may get access to your FSA money earlier in the year than an HSA account. For example, FSA funds are available to spend in their entirety at the beginning of the plan year; however, with an HSA, funds accumulate only as you contribute. Also, you must be enrolled in an FSA plan through your employer; it is an employee benefit that anyone can contribute to as long as you’re eligible. An HSA plan, on the other hand, is determined by your health insurance and you must be enrolled in a High Deductible Health Plan to get access to it.

What is an HSA?

A Health Savings Account (HSA) is a type of personal savings account that lets you set aside money before taxes to pay for healthcare costs, which can mean paying less overall for healthcare services.

Just like a bank account, you open a spending account which has a debit card connected to it that you can use for healthcare services. But instead of a bank controlling it, your HSA account is managed by your employer or a vendor that your employer assigns to manage the account.

What can I use my HSA for?
You can use it to pay for qualified, out-of-pocket medical costs like ER visits, doctor appointments, prescription drugs, therapy, and more. You can also use your HSA to pay for deductibles, copayments, coinsurance, and a handful of other qualifying expenses. Generally, you cannot use it to pay insurance premiums; however, if you’re signed up for a High Deductible Health Plan (a health plan that only covers preventive services before the deductible is fully paid), your monthly premium will typically be lower.

How do I add money into my HSA?
You can contribute to your HSA via payroll at your company, which can reduce your taxable income. Your employer may also make an initial contribution to your HSA when you’re signing up for it.

Can I use the money from my HSA anytime?
Yes, you can. HSA funds roll over year to year if you don’t spend all of the funds. However, you can only contribute to an HSA if you’re signed up for a High Deductible Health Plan. Also, once you begin any Medicare coverage, you will no longer be able to contribute to your account. However, you can continue to use your HSA funds to pay for qualified medical expenses on a tax-free basis.

How do I open an HSA?
If you’re signed up for a High Deductible Health Plan, you may be able to sign up for an HSA through your health insurance company. But, not all health insurance companies offer HSA accounts.
 
What are other benefits of an HSA?
You pay no federal income tax—which means you aren’t taxed on money you put into it, or on interest earned. This is called a triple tax advantage—any contributions, interest, investment gains, and withdrawals for qualified healthcare expenses are all federal tax-free. You also don’t need to worry about paying tax on withdrawals for qualified medical expenses, like doctor visits and more. Another benefit is that you can use your HSA to pay for qualified medical expenses for your spouse or dependents, even if they’re not on your High Deductible Health Plan. You can also invest the money in your HRA, so that it earns interest and can potentially grow over the long term. Some people invest all of the funds in their HSA or only a portion. And finally, unlike a Flexible Spending Account, you own your HSA account and can hold onto it even if you leave your employer.

What is an out-of-pocket maximum?

An out-of-pocket maximum, or out-of-pocket limit, is the amount of money you’ll pay before your health plan pays for all of your in-network healthcare costs. In other words, it’s the maximum amount you’ll spend in any given year for healthcare. Once you reach your out-of-pocket max, things like copayments and coinsurance for in-network doctors will be completely covered by your health plan.

Will I ever exceed the out-of-pocket maximum?
When it comes to in-network healthcare—nope, you won’t. The actual amount of your out-of-pocket maximum will vary depending on your plan, but you will never exceed your plan’s out-of-pocket max. In fact, that’s controlled by federal law.

What isn’t included in my out-of-pocket maximum?
Your out-of-pocket maximum does not include monthly premiums, out-of-network care and services, expenses that aren’t covered by your healthcare plan, or any costs above the allowed amount for a service that a provider might charge. That’s why it’s always a good idea to choose in-network care when possible.

Does an out-of-pocket maximum affect me before I reach it?
For sure. You should check out the out-of-pocket max before enrolling in a health plan. Once you know, it  can help you plan for your future services and help you avoid any major financial setbacks.

Can I choose my out-of-pocket maximum?
While you can’t actually choose the amount when enrolling, you’ll often have the option of selecting between plans with different out-of-pocket maxes. You might be thinking, “why wouldn’t I just choose the plan with the lowest out-of-pocket max?” This is because plans with a lower out-of-pocket maximum generally have a higher premium, while plans with a higher out-of-pocket maximum generally have a lower premium cost. So basically, you typically pay more monthly to reach your out-of-pocket max earlier.

How is an out-of-pocket maximum different from a deductible?
A deductible is the amount of money you have to pay for covered services before your insurance begins to pay for a portion. An out-of-pocket maximum is the amount of money you have you have to pay before your insurance pays for 100% of covered services. The good news is that, as you contribute to your deductible, you’re also contributing to your out-of-pocket maximum.

How can Included Health help?
If you still have questions about how your health benefits, Included Health can help. Our benefits experts can talk with you about your unique needs and solve any healthcare question you might have, from billing questions to finding out what’s covered with your plan. You can also connect with our experts to make sure you’re not overpaying for care and find more ways to save. Included Health is available for select Health Plans and Employers.