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Understanding Insurance Terms

Common Insurance Terms


Happy New Years! It’s now that time of year when most health insurance policies renew.  J  Sometimes the terminology in health insurance policies can be a little confusing, so we are here to help! 

We have chosen a few common insurance terms and explained them in a bit more detail so they are easier to understand.  Remember, it’s always a good idea to call your insurance company with any kind of question or clarification you may need.  They are always willing to help, as is Hart Medical Equipment!


What is a Deductible?

The deductible is a set dollar amount the patient must pay before the insurance company starts picking up some of the cost for the medical benefits. Once you meet your deductible, the insurance will pick up a set percentage of what the patient is responsible for and leave them with a coinsurance to pay.


What is a Coinsurance?

Coinsurance is a set percentage of coverage the patient is responsible for paying, i.e. 10% of a monthly rental. The insurance will pick up the remaining cost left over for the services or items received after the portion the patient is financial responsible for paying. The patient pays the coinsurance percentage until they meet their plan’s set out-of-pocket dollar amount.


What is an Out-of-Pocket?

The out-of-pocket is a set dollar amount the patient must pay before the insurance company will cover all additional costs. After you meet your deductible, your coinsurance will accumulate to meet your out of pocket.  Once you meet your out of pocket dollar amount, your insurance will cover 100% of the costs.


What is the difference between Copay and Coinsurance?

Most insurances have a set copay or dollar amount you pay when visiting the doctor’s office each time (i.e. $25 for primary doctors or $50 for specialty offices).  Most insurance plans have a coinsurance or a percentage of the total cost of the durable medical equipment.


What is Coordination of Benefits (COB)?

Coordination of benefits is the process of determining which of two or more insurance policies will have the primary responsibility of processing/paying a claim and to the extent the other policies will contribute.


Subscriber vs. Dependents

The subscriber is the primary enrollee for the plan. Dependents are those who rely on the primary enrollee for insurance coverage (i.e. child, spouse, domestic partner). If at any time the primary enrollee terminates insurance, the dependents will also have their coverage terminated.

Individual costs vs. Family costs

Each enrollee on a family plan has their own out-of-pocket (OOP) and deductible to meet. There is also an out-of-pocket and deductible for the entire family that is normally higher than the individual ones. The family plans have the group deductible and coinsurance to help save the whole family money. If there is a family of 4 on an insurance plan, two people have met their individual deductible and the other two have not, but the family deductible has been met. Since the family deductible has been met, the two people who have not met their individual deductibles, do not need to meet their individual deductibles.  


In-Network vs. Out-of-Network Providers

Insurance plans have set providers that are considered in-network and offer their services at a lower copay or a lower coinsurance. For many plans, out-of-network providers are normally covered at a lower rate by the plan, leaving the patients with a higher copay or higher coinsurance. Most plans have a preferred provider for DME, hospitals, doctors etc. If you choose to use a preferred provider, they are usually considered to be in-network and at a lower cost to the patient.


What is a Medicare Advantage Plan?

A Medicare advantage plan is an insurance policy that groups together Medicare coverage and a basic policy. (i.e. Medicare Plus Blue, Hap Senior Plus, Blue Care Network Advantage). When processing orders through Durable Medical Equipment (DME) companies, pharmacies or doctors’ offices, these type of plans are billed as one policy verses two separate policies. These type of plans follow Medicare guidelines, but may offer discounts to the patients when they are choosing their insurance benefits.


What is a Supplemental Plan?

A supplemental plan is a separate insurance policy that is billed separately from their main insurance. If a patient has a supplemental plan and we are trying to bill the insurance, we would bill Medicare AND the supplemental coverage (i.e. Medicare and AARP). These are billed separately rather than together like an advantage plan and usually cover more of the cost for the patient, but can cost more on a monthly basis to purchase the insurance coverage.


What are Medicaid Care Management Plans?

Medicaid care management plans are insurance plans where there is a basic plan coverage and Medicaid is bundled together when billed. (i.e. HAP Midwest, Molina Medicaid, Meridian Medicaid). Insurance will follow Medicaid guidelines, but would be verified and billed through one insurance company. This is not a straight Medicaid plan.


What are Riders on a plan?

When a patient’s insurance policy doesn’t cover specific items, they can purchase additional “rider(s)” from the insurance company to cover any missing areas from a plan. This would be an additional cost to the patient each month when they purchase their plan.


We hope that helped clear up your understanding of the different terminology used in insurance plans. We know insurance plans can be confusing, so we’re always happy to help explain and ease any concerns.


To view a list of insurances Hart Medical Equipment accepts, or to view and pay your bill online, please visit