Understanding The Basics of Health Insurance

The Anatomy of a Health Plan


From 30,000 feet above, your health insurance plan is an intricate and interrelated system whose fundamental purpose is to reduce the cost of medical services. Understanding the basics of health insurance and how the insurance company processes claims will make you a wiser consumer of healthcare services.

While each health insurance plan may have its unique features, they all adhere to a common framework involving deductibles, copays, coinsurance, out-of-pocket limits, provider networks, and coverage limitations or exclusions.

These are some of the levers and dials inside a comprehensive health plan that translate into that simple medical ID card in your wallet. Gaining an understanding of these elements and what your plan does and doesn’t cover can enable you to navigate your healthcare journey with more peace and confidence.

Let’s take a closer look at some of the inner workings of a group health insurance plan:

Common Elements of a Health Insurance Plan – 


  • Premium: This is the regular payment you make to maintain your health insurance coverage. It’s similar to a subscription fee, ensuring that your plan remains active. Premiums can vary depending on the level of coverage and the type of plan you choose, such as individual or family coverage.
  • Deductible: A deductible is the amount you must pay out of your pocket for covered medical expenses before your insurance starts contributing. Typically, the higher the deductible, the lower your premium, but the more you’ll need to pay upfront when seeking healthcare services.
  • Copay: A copay is a fixed amount you pay for certain medical services, such as doctor’s visits or prescription medications. Copays are usually set at a specific amount, making it easier to budget for routine healthcare expenses. Typically office visit copays are not subject to the deductible  
  • Coinsurance: Coinsurance is a cost-sharing arrangement where you and your insurance provider each pay a percentage of your healthcare expenses after you’ve met your deductible. For example, if your plan has a 20% coinsurance rate, you’ll pay 20% of the cost, and your insurer will cover the remaining 80%.
  • Prescription Benefits: Prescription coverage typically involves a tiered system, where you pay different copayments or coinsurance amounts depending on the type of medication – generic, preferred brand, non-preferred brand, or specialty. Understanding your plan’s prescription benefits is crucial, as it can significantly impact your out-of-pocket costs for necessary medications.
  • Preventative services such as annual check ups and certain wellness screenings are typically covered at 100% (without meeting the deductible). The government list of preventive services covered at 100% are listed at HHS Preventive Services  
  • Out of Pocket Limit: This is the maximum amount you’ll have to pay for covered medical expenses in a given calendar year. Once you reach this limit, your insurance plan will typically cover 100% of any additional covered expenses, providing you with financial protection against high healthcare costs.
  • Your Plan’s Provider Network: All health insurance plans, regardless of their type or structure, typically maintain a network of “approved participating providers”. Using these providers assure you’ll receive the biggest benefit for your dollar. If you stray outside this network, your medical care costs will rise dramatically. You can find a list of network providers within a radius of your zip code on your health insurance website portal.

How It All Comes Together

Let’s use an example of how these elements may play out in real time. Let’s assume you have a plan with a $2500 deductible, 30% coinsurance, and a $8500 out-of-pocket-limit. Let’s further assume that you haven’t had any medical expenses all year and suddenly you need surgery: the total bill will be $200,000. 

First, you’ll want to confirm you are in the carrier’s PPO or HMO network to utilize the cost saving advantages of your health plan. Next, you’ll have to pay the first $2,500 of expenses; this is the plan’s deductible. Once you’ve met the deductible, your coinsurance kicks in and your plan pays 70% of the remaining covered expenses. This means you’ll pay 30% of the cost until your total out of pocket is $8500, which includes your deductible and any prescription costs you may have incurred through the year. Thereafter, your plan will pay 100% for all covered services. In short, instead of having to pay a $200,000 bill, you’ll only be responsible $8,500. That’s the power and benefit of health insurance.

While all plans vary to some degree, most plans have similar milestones and thresholds that have to be met before an insurance company starts paying some or all of your medical claims. And as you can see, the benefits of having a health insurance plan are essential to navigating the uncertainty we all face as we age into the future. 

At Carmel Bay Group, we’re here for your journey- to be a guiding light and a trusted advisor when you need. We’re here to break the complexity down and help you manage your benefits in a way that elevates your life and the people you care about. 


Carmel Bay Group specializes in the employee benefit needs of employers and employees in California and other states.  We are a well established boutique insurance agency out of Carmel, California that designs unique and appealing group health insurance plans for employers and small businesses. Our services include group benefits and administration, compliance support, executive benefits and life, annuities, disability insurance and long term care.

Learn more about the Carmel Bay Group difference –