Talk Health Insurance

Health insurance, in plain English

Your plan has its own language. Here is the translation.

Deductible, coinsurance, allowed amount, out-of-pocket maximum: US health insurance runs on words that decide what you pay. Talk Health Insurance explains those words and the arithmetic behind them, using the federal government's own definitions. Nothing is sold here, and no plan is recommended.

Open the glossary Start with how costs work
Two overlapping speech bubbles, one dark and one coral, above a row of four cost blocks that rise in height and then level off under a dashed line.
A question, an answer, and the costs underneath them.

Questions people ask

Short answers first, the detail one click away

  • Why did I pay the full bill when I have insurance?

    Often because the deductible has not been met yet. Until it is, many plans expect you to pay for covered care yourself, at the plan's negotiated rate.

    How the deductible works

  • Is there a limit to what I can be charged in a year?

    For covered, in-network care, the out-of-pocket maximum is that limit. Premiums, out-of-network care and services the plan does not cover sit outside it.

    What the ceiling covers

  • What is the difference between an HMO and a PPO?

    Mostly how strictly the plan sticks to its network and whether you need a referral to see a specialist. Costs and rules differ by plan, not just by type.

    Plan types explained

  • Can an out-of-network doctor bill me for the difference?

    That is called balance billing. The No Surprises Act bans it in several common situations, including most emergency care.

    Networks and surprise bills

  • How do I compare two plans fairly?

    Most plans must provide a Summary of Benefits and Coverage in the same standard layout, so you can line two of them up row by row.

    Reading an SBC

  • Why does one prescription cost more than another?

    Plans list covered drugs on a formulary and often group them into tiers, with different cost sharing for each tier.

    Drug lists and tiers

The explainers

Six explainers on how the costs work

Each explainer takes one part of a health plan and walks through it slowly: what the terms mean, the order they apply in, and an illustrative example with round, made-up numbers. They build on each other, so the first one is the best place to start.

  1. Premiums, deductibles, copays and coinsurance: who pays what, and when

    The four core cost words and the order they apply in.

  2. The out-of-pocket maximum: the ceiling on a year of covered costs

    What the yearly ceiling caps, and what never counts toward it.

  3. HMO, PPO, EPO, POS and HDHP: what the plan-type letters mean

    Networks, referrals and the HDHP plus HSA pairing.

  4. In network, out of network and surprise bills

    Network pricing, balance billing and No Surprises Act protections.

  5. How to read a Summary of Benefits and Coverage

    The standard plan summary, read section by section.

  6. Drug lists and tiers: how prescription coverage is priced

    Formularies, cost tiers and the rules attached to some drugs.

The glossary

Every term, with what it means on a bill

The glossary covers the words you will meet on a plan summary, an explanation of benefits or a medical bill. Each entry gives the plain meaning, then a line on why it matters when money changes hands, then a pointer to the explainer that goes deeper.

Browse the glossary, A to Z

  • Allowed amountThe most a plan will pay for a covered service. Your coinsurance is worked out from this figure, not from the provider's original charge.
  • Cost sharingYour share of the cost of covered care: deductibles, copayments and coinsurance. Premiums are not part of it.
  • FormularyThe list of prescription drugs a plan covers. If a drug is not on it, the plan may not pay for it without an exception.

How this site works

Official definitions, plain words, no sales

Health insurance is a money topic with real consequences, so the rules here are strict. Read the editorial policy.

  • Government sources onlyEvery page is based on HealthCare.gov, CMS, the Department of Labor, the IRS or Medicare.gov, and lists the documents it uses.
  • Examples are made upWorked examples use round, invented numbers and describe no real plan or person. Your plan's own documents always decide.
  • Nothing to sellThis is not an insurer, broker or agent. There are no quotes, forms, affiliate links, ads or tracking scripts.