co-pay = a specified dollar amount that an individual pays for health-care services at the time the service is rendered.
Example: You could have an insurance plan where each visit to a doctor's office has a $30 co-pay. This means that you will go to the doctor and pay just $30 for that office visit, even though he may normally charge $100 or more. [Tests or treatments may cost extra which you will be responsible for paying in full]
co-insurance = a certain percentage that an individual pays for health-care services covered by his/her insurance plan.
Example: You acquire a health insurance plan where the bills are split 70/30 between the insurance company and you. The insurance company pays 70% and you pay the remaining 30%. That remainder is the co-insurance.
covered services = anything and everything that your insurance company is willing to pay for, usually that which is deemed medically necessary. There can be quite a few exclusions so read your policy carefully.
Example: You are in an accident which results in a broken nose, therefore your insurance may help cover the expenses involved with doctors visits, time in a hospital, plus reconstructive surgery. But if you think your nose is too big, therefore you want to have plastic surgery, the consultation and all expenses to "fix" your nose will most likely not be covered/paid by the insurance company.
deductible = the amount that an individual must pay out of his/her own pocket before the insurance company will begin to pay. (deductibles are often "waived" for office visit co-pays)
Example: Your health insurance plan has an annual deductible of $1000. This means you will pay the first $1000 of medical bills each year; however, if the plan has seperate co-pays for doctor's office visits, then you just pay the co-pay even if you have not yet reached your deductible for the year.
in-network = doctors and hospitals who have already agreed to accept payment from a particular insurance company. These healthcare providers in various cities and states form a group called a network, typically providing discounted service.
Example: You purchase insurance from XYZ-Insurance Company and are told that you will pay a certain amount for your care as long as you go to in-network providers. (You will pay more if you go to out-of-network providers.) Therefore you can call the company or go online for a list of in-network providers in your area, or you can call around and ask "Do you take XYZ insurance?"
out-of-network = all doctors and hospitals who are not part of a particular insurance company's network of healthcare providers.
Example: You have open-heart surgery at Cardiologists-R-US but they do not accept your insurance from XYZ Insurance Co.; therefore, you will have to pay the big bill and file paperwork with XYZ for partial reimbursement. XYZ will pay you less than they would have paid an in-network provider, thus you will pay more.
out of pocket max = the total amount of money an individual must pay out of his/her own pocket for covered services. (Annually)
Example: Lets say you have health problems and require an organ transplant. All services are covered and the total bill is $150,000. If your out of pocket max is $5000, then the insurance company pays $145,000. Any additional covered services (that year) are paid 100% by the insurance company because you are already maxed out.
policy = the paperwork given to you from an insurance company outlining specific details of your paid coverage.
Example: A 10-page booklet of details regarding which services the insurance company will and will not pay, the effective date (when coverage first began), the premium you must pay, etc. Often comes with a proof-of-insurance card to carry with you to the doctor that has your specific policy number on it.
premium = the amount you must pay to keep your policy active; it can be paid monthly, quarterly, semi-annually, or annually.
Example: If you pay $150 per month for your health insurance, then you have a monthly premium of $150.