Health Literacy - Terms to Know & Understanding Them!
October 6, 2025
Understanding the 4 Key Components of a Health Insurance Policy
In everyday terms, co-pays are like the set cover charge at the doctor’s office: you pay your fixed share, and insurance covers the rest right away.
Health insurance can feel overwhelming—full of terms, numbers, and fine print that don’t always make sense at first glance. But when you break it down, most health insurance policies are built around four main cost-sharing components: deductible, co-pay, coinsurance, and maximum out-of-pocket (MOOP).
Understanding these four pieces is essential, because they determine not only how much you pay when you use medical services, but also how quickly your plan begins to share costs with you. Let’s walk through each in simple, everyday language so you can feel more confident about how your policy works.
1. Deductible: Your Upfront Responsibility
The deductible is the amount you pay out of pocket before your insurance company begins covering certain services. Think of it like the entrance fee you must pay before your insurance kicks in for many covered benefits.
For example, if your deductible is $2,000, you are responsible for the first $2,000 of eligible medical expenses each year. After you reach that amount, your insurance will begin to share the cost of your care, usually through coinsurance or co-pays.
A few important points about deductibles:
- Not all services apply. Many plans allow you to see your primary care doctor, receive preventive screenings, or get generic prescriptions without paying toward your deductible first. Preventive care (like annual check-ups or vaccines) is almost always covered at no cost under the Affordable Care Act.
- Family deductibles work differently. If you have a family plan, there is usually both an individual deductible and a family deductible. Once one person meets their individual deductible, the plan starts helping with their costs. Once the total family deductible is met, coverage expands for everyone in the household.
- High vs. low deductibles. Plans with higher deductibles usually come with lower monthly premiums. Plans with lower deductibles often have higher premiums. The right balance depends on your expected healthcare usage.
In short, your deductible is the foundation of your plan. Until you meet it, you’re largely paying medical costs yourself.
2. Co-Pay: A Flat Fee at the Time of Service
A co-pay (short for “copayment”) is a fixed amount you pay when receiving certain medical services, such as visiting your doctor, filling a prescription, or going to urgent care.
For example:
- $25 to see your primary care doctor.
- $50 for a specialist visit.
- $15 for a generic prescription.
The key thing to know is that co-pays are predictable. Whether your doctor charges $150 or $250 for the visit, you still pay the same flat fee.
A few notes about co-pays:
- Co-pays are due at the time of service, making them one of the most visible costs of health insurance.
- They may or may not count toward your deductible, depending on your plan. Always check your policy details.
- Many people appreciate co-pays because they provide certainty—you know exactly what you’ll owe for certain services.
In everyday terms, co-pays are like the set cover charge at the doctor’s office: you pay your fixed share, and insurance covers the rest right away.
3. Coinsurance: Sharing Costs with Your Insurance Company
While a co-pay is a flat fee, coinsurance is a percentage of the bill that you pay once your deductible has been met. This means your costs will vary depending on the price of the service.
For example, let’s say your plan includes 20% coinsurance:
- You have already met your deductible.
- You need an MRI that costs $1,000.
- Your share is 20% = $200, and insurance pays the remaining $800.
Coinsurance can apply to hospital stays, imaging, outpatient procedures, or other higher-cost services. It ensures that you and your insurer both share responsibility for expenses after your deductible is met.
A few key points:
- Coinsurance only kicks in after the deductible has been satisfied.
- The percentage varies by plan—commonly 10%, 20%, or 30%.
- If you haven’t met your deductible yet, you pay the full cost of the service.
Coinsurance is like splitting the bill with your insurance company—you both cover part of the cost, but the insurer usually pays the larger share.
4. Maximum Out-of-Pocket (MOOP): Your Safety Net
The maximum out-of-pocket (MOOP) is the most you will have to pay for covered services in a plan year. Once you reach this amount, your insurance company pays 100% of covered expenses for the rest of the year.
Here’s how it works:
- Your deductible, co-pays, and coinsurance all count toward this maximum.
- Premiums (your monthly payments) do not count toward it.
- Once you hit the MOOP, you are fully protected from additional covered medical costs for the remainder of the plan year.
For example:
- Your plan has a $6,500 MOOP.
- Over the year, you pay $2,000 to meet your deductible, $1,500 in coinsurance, and $3,000 in co-pays.
- That totals $6,500, meaning you’ve reached your maximum out-of-pocket.
- From that point forward, your insurance pays 100% of all covered services until the new plan year begins.
This is the ultimate financial protection built into every health insurance policy. It ensures that no matter how high your medical costs go, there’s a ceiling on what you’ll owe.
Putting It All Together
Understanding these four components—deductible, co-pay, coinsurance, and maximum out-of-pocket—gives you a clearer picture of how your policy works in real life. Let’s consider an example:
- You have a plan with a $2,000 deductible, 20% coinsurance, $25 co-pay for office visits, and a $6,500 MOOP.
- You go to your doctor for a sick visit → $25 co-pay.
- Later, you need blood work costing $300. Since you haven’t met your deductible yet, you pay the full $300.
- After meeting your $2,000 deductible through several services, you need an MRI costing $1,000. Now, instead of paying the full amount, you pay 20% = $200, and insurance covers the rest.
- Over the course of the year, once your combined payments hit $6,500, your insurer takes over and pays 100% of covered costs.
Final Thoughts
Health insurance can be intimidating but breaking it into these four pieces makes it easier to understand.
- Deductible: what you pay first.
- Co-pay: flat fee for certain visits or prescriptions.
- Coinsurance: percentage of costs after your deductible.
- Maximum Out-of-Pocket: the cap that protects you from runaway expenses.
With this framework, you can compare plans more confidently, understand your true potential costs, and make choices that fit your healthcare needs and budget.
Individual / ACA Marketplace Plans 1. Premiums Are Rising Sharply Insurers in many states are proposing increases in ACA marketplace premiums of 10–27% for 2026. Some preliminary data show a median premium increase around 18% nationwide. 2. Out-of-Pocket Maximums & Deductibles Increasing With healthcare costs and inflation, government rules are pushing up the limits: what you pay in deductibles, copays, and the most you’ll ever pay in a year is going up. For many ACA-compliant plans, the maximum out-of-pocket is moving significantly higher in 2026. 3. Subsidies (Premium Tax Credits) Might Shrink Enhanced premium tax credits that have helped many people afford marketplace plans are set to expire at the end of 2025 unless extended by Congress. When they expire, many people will see their net premiums (what you pay after subsidies) increase—possibly by a large margin. 4. Eligibility Rules and Participation Changes There may also be changes in who qualifies for what levels of help, and how much. Household income, size, and even your recent medical needs could affect the cost and availability of plans more than before. Medicare 1. Part B & Part D Premiums and Cost Sharing Are Increasing Medicare Part B monthly premiums and Part D premiums are projected to go up in 2026. For example, the base beneficiary premium for Part D is expected to increase about 6%, while Part B premium increases are more significant. 2. Out-of-Pocket Drug Caps Go Up The maximum out-of-pocket cost for prescription drugs under Medicare Part D will increase: from $2,000 in 2025 to $2,100 in 2026. 3. Medicare Prescription Payment Plan (MPPP) Changes The MPPP, which helps you spread prescription drug costs across the year rather than paying full cost at the counter every time, will auto-renew unless you opt out. Also, plan sponsors must process opt-outs within three days. 4. Updates to Medicare Advantage (MA), Part D, Dual-Eligible Plans (D-SNPs), and Star Ratings CMS’s 2026 final rule introduces nuanced changes in how plans are rated, how prescription drug benefits are structured, and enhancements/modifications for Dual Eligible Special Needs Plans. Why These Changes Matter for You These are not just abstract policy shifts — they can affect your wallet, your coverage, your access to care, and how much protection you really have. Here’s why reviewing your coverage matters: • Costs Could Go Up Significantly With premiums, out-of-pocket maximums, and deductibles rising, what seemed affordable last year may look very different in 2026. If you rely on subsidies for ACA plans, those shrinking could be a big hit. • Your Health Situation May Have Changed If your health needs have changed (new medications, more frequent doctor visits, upcoming surgeries, etc.), the plan you had before may no longer serve you well. A plan that seemed adequate might now expose you to large costs. • Benefit Designs Differ Widely Even within Medicare Advantage, Part D, and ACA plans, plan features vary: prescription drug formularies, preferred providers, prior-authorization rules, network coverage, and perks are not uniform. A review helps you match plan features to your actual needs (doctors you use, medications, specialists, etc.). • Avoid Gaps, Surprises, & Administrative Issues Auto-renewals or changes might happen that you miss. For instance, with MPPP auto-renewing, you might stay in a plan whose new cost structure works less well for you. Provider directories may change. If you don’t check, you could discover after the fact that your usual doctor isn’t in-network. • Opportunity to Optimize With change comes opportunity. You may find a cheaper plan, more subsidy, or better coverage that suits your situation. You might re-evaluate whether a high-deductible plan with HSA works, or perhaps a more robust Part D plan is worth the premium. A consult helps you see those trade-offs and make an informed decision. What to Ask / Look at During Your Consult or Review When you sit down to review, whether with a licensed agent, broker, or counselor, here are items you’ll want to cover: Projected total costs: premiums + deductibles + drug costs + copays + out-of-pocket maximums Changes to subsidies / tax-credits for ACA plans Plan networks: are your doctors / hospitals included? Drug formularies: are your prescription drugs covered? Are there shifts in prior authorization? Extra benefits (vision, dental, hearing, wellness perks) and trade-offs for those extras Whether your Medicare Advantage plan or Original Medicare plus a supplement better serves you, given new MA changes Timing: open enrollment periods, deadlines, required paperwork for subsidies, verification of income, etc. Conclusion: Why You Should Act Now Given all the changes ahead in 2026, waiting to review can leave you exposed: to cost increases you didn’t anticipate, to being “locked in” to a plan that no longer fits, or missing out on new benefits. Booking a consult / review now gives you lead time to: Understand what changes will hit you Adjust your budget or savings to cover increases Shop smartly and compare alternatives before open enrollment ends Make sure paperwork is in order so you don’t lose subsidies or coverage Give us a call at 706-257-5073 to schedule your 2026 consult now!
September is recognized as Blood Cancer Awareness Month, a time when individuals, families, organizations, and communities come together to shine a light on a disease that affects so many lives. At Crawford Benefits, this cause is especially close to our hearts. We know firsthand how important awareness and education can be, and this September we are showing our support by turning things a little orange, the color that symbolizes blood cancer awareness. Wearing or displaying orange may seem small, but it is a powerful reminder of the ongoing fight against leukemia, lymphoma, myeloma, and other blood cancers. By dedicating a month to this cause, we hope to encourage early detection, raise critical support for patients and their families, and inspire action within our community. Blood cancers are unique because they affect the very lifeline of the body, the blood, bone marrow, and lymphatic system. Unlike many other cancers that form solid tumors, blood cancers circulate through the body, making them harder to detect in their early stages. That is why awareness is so vital. When people understand what symptoms to watch for and when to speak up, lives can be saved. Some of the most common signs of blood cancers include persistent fatigue or weakness, frequent infections, unexplained weight loss, easy bruising or bleeding, and swollen lymph nodes. Unfortunately, these symptoms can often be mistaken for other, less serious conditions, which can delay diagnosis. The more we talk about these warning signs, the better chance people have at recognizing when something might be wrong and getting help as early as possible. For many families, a blood cancer diagnosis can be overwhelming. It often brings uncertainty, countless medical appointments, and emotional and financial strain. Yet, in the midst of this challenge, stories of resilience, community support, and groundbreaking medical advances provide hope. Treatments such as bone marrow transplants, chemotherapy, immunotherapy, and CAR T-cell therapy are improving outcomes for patients every day. Continued progress in research is possible because of awareness months like this one, which raise funding and spark conversations that keep blood cancer in the spotlight. At Crawford Benefits, our commitment goes beyond simply acknowledging Blood Cancer Awareness Month. We want to encourage real action. One of the simplest yet most impactful ways to get involved is to donate blood. Cancer patients often rely on blood transfusions as part of their treatment, and every donation truly makes a difference. Another powerful step is to register as a bone marrow donor. Many patients with blood cancer depend on bone marrow or stem cell transplants to survive, but finding a matching donor can be difficult. By joining the registry, you could one day give someone the gift of life. Supporting research organizations and patient advocacy groups is also a meaningful way to contribute. Donations help fund groundbreaking studies, provide patient services, and support families during some of the most difficult times in their lives. Even if financial giving is not possible, simply sharing information with friends and family helps spread awareness. Wearing orange, posting about Blood Cancer Awareness Month on social media, or participating in a local fundraising event are small actions that create a ripple effect of education and support. As we reflect on this month, it is important to remember that awareness is not just about statistics or facts, it is about people. It is about honoring those who have lost their lives, supporting those currently in the fight, and standing with caregivers who give so much of themselves. It is also about building hope for the future, where better treatments and maybe even cures become a reality. Awareness months like this remind us that we are not powerless in the face of cancer. Each of us has something to contribute, whether it is time, resources, or simply compassion. We encourage everyone to take a moment this September to learn more about blood cancers and what you can do to help. Check in on loved ones, talk about the signs and symptoms, and look for ways to get involved. Together, as a community, we can raise our voices for a cause that matters deeply to so many. When we unite under the color orange, we send a message of strength, resilience, and unwavering support to those impacted by blood cancer. This September, let us remember that awareness leads to action, and action leads to hope. By donating blood, registering as a bone marrow donor, supporting organizations, and sharing information, we all have the power to make a difference. We stand with the blood cancer community this month and every month, and we invite you to join us in spreading awareness and fostering change. Together, we can turn compassion into action and bring hope to those who need it most.