February 22, 2025

Health Insurance Terms

John Dang M.D.

Payment for healthcare is divided into two components, payments made directly to your insurance company and payments made to healthcare services, through your insurance. Let’s break this down and look at some of the more common terms associated with healthcare fees.

These are (usually) monthly payments paid directly do your insurance company to maintain your health insurance plan; many employers may help with part or all of these payments.

Usually, a healthcare plan will not pay 100% of medical costs for patients. A certain percentage of healthcare fees (hospitalizations, office visits, procedures) will be borne by patients. This is done in a variety of ways: 

A fixed flat rate, usually associated with office/urgent care/emergency care visits. These are paid before the visit.

Initial amount of healthcare fees that patients are 100% responsible for. After this amount has been met, the healthcare insurance company will pay for the remainder of healthcare fees thereafter. The deductible resets each year on January 1^st. Deductibles are paid to healthcare services directly by patients, usually a few weeks after the service.

Instead of deductible, some plans have patient pay a certain fixed percentage of all their healthcare costs. Co-insurances are paid to healthcare services directly by patients, usually a few weeks after the service.

What are insurance adjustments? Simply, healthcare organizations bill your insurance a certain amount for services rendered; if this organization is in network, you and your insurance company will pay a lower fee than the billed amount. Insurance adjustment is the difference.