Insurance Basics

Understanding How Medical Insurance Really Works

Why This Matters

Many patients do not understand their own insurance. They often believe that having insurance means everything is covered. Front desk staff help set clear expectations in a friendly, confident way.

Educated patients are happier patients.

Key Insurance Terms Explained

Premium: The monthly cost the patient pays to have insurance; it does not go toward bills.

Deductible: Amount the patient must pay out-of-pocket each year before insurance shares the cost.

Coinsurance: The percentage of cost the patient pays after meeting the deductible.

Copay: A fixed dollar amount paid for specific visits or services.

Out-of-Pocket Maximum: The most a patient pays in a year; after this, insurance pays 100%.

How to Explain This to Patients

Discuss their benefits during the Report of Findings before treatment begins. Explain deductible status, copay amounts, and expected coinsurance in simple terms. Use clear examples such as: ‘You have a $1,000 deductible, and you’ve met $300 so far.’ Avoid guessing—verify benefits first, then educate the patient with confidence.

Quick Reference Chart

Premium: Patient pays monthly | Example: $300/month

Deductible: Patient pays first | Example: $1000 before coverage

Coinsurance: Patient & insurance share | Example: 20% patient / 80% insurance

Copay: Patient pays per visit | Example: $20 per visit

Out-of-Pocket Max: Patient limit | Example: After $5000, insurance pays 100%

For more resources, visit the CARE Helpdesk Portal ® Knowledge Base ® Insurance Basics.