Insurance Confusion

Lets face it, insurance terminology can be confusing, these terms make it hard for people to truly understand what they owe or what they are responsible for when they go to a doctor, hospital, or service provider.

As insurance professionals, Phoenix Captive employees run into people everyday that are confused by insurance terms simply because these terms are made to be that way.

Here are some of the most common terms Phoenix comes across and a brief explanation of each.


This a set dollar amount for a covered service that you must pay when visiting a doctor, specialist, urgent care or emergency room.

Typically, these are paid on the spot at your visit or for a prescription.

(In general, a co-pay does not count towards deductible. They are typically applied to the Out of Pocket Limit.)


Under most insurance plans your health care bills are not covered right away, typically you are asked to pay a certain amount before coverage “kicks-in”, this is called the deductible.

It is how much your plan requires you to pay before the insurance carrier starts to cover your bills.

Because of this a good rule of thumb typically is cheaper the plan, the higher the deductible. 


Some insurance plans expect to pay a percentage of the bill even after you’ve met your deductible. For example, you could be on the hook for 20% or 30% of the bill while in the insurer pays the rest.

This is what is known as co-insurance, as the insurance carrier is sharing part of the cost of the covered service.

Out of Pocket Limit

While deductible and coinsurance could mean you end up paying a lot of money for health care, the good news is there is a limit to what you’ll be responsible for paying. This is what is known as the Out of Pocket Limit, If you end up with thousands of dollars of medical bills one year, the insurance will cover 100% of your medical services for the rest of the plan or calendar year.

Explanation of Benefits

Often when people receive these they are mistaken for the bill, it is not. An EOB is just the overview of what your doctor billed to the insurance company and what the insurer has agreed to cover. This typically give you an estimated cost of how much you might be expected to pay. The medical provider will send a bill separately that is your responsibility to pay.

This article was written by Phoenix Captive Solutions C.F.O. Blake Coats, any views or opinions do not necessarily reflect the opinions of either Phoenix Captive Solutions LLC, or any associated entities.  

Feel free to write to Blake at  

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