Insurance words, translated

This is parent-to-parent guidance, not legal or insurance advice. Your own plan documents and your insurer’s written answers are what actually govern your coverage.

The words

Tap any term to open it.

Premium

What you pay every month just to have the insurance, whether or not you use it. Premiums do not count toward your deductible or your out-of-pocket maximum — this is the cost of the door, not the cost of walking through it.

Deductible

The amount you pay yourself each plan year before the insurance starts sharing costs. It resets every plan year — which is why January and February are the expensive months for therapy families.

Copay

A flat amount you pay for a specific visit — say $30 for a therapy session — regardless of what the visit costs. Predictable, which makes it the easiest number to budget around.

Coinsurance

A percentage instead of a flat fee. If your coinsurance is 20%, then after your deductible you pay 20 cents of every dollar the plan allows and the insurer pays 80. Unlike a copay, this number moves with the price.

Out-of-pocket maximum (OOP max)

The most you can pay in a plan year for covered, in-network care. Once you hit it, the plan pays 100% of covered services for the rest of the year. Premiums don’t count toward it, and out-of-network care often doesn’t either. For families with intensive therapy, this is the number that makes the year survivable.

In-network vs. out-of-network

In-network providers have a contract with your insurer and accept a negotiated price (the “allowed amount”). Out-of-network providers don’t — so your plan may cover less, or nothing, and the provider may bill you the difference between their charge and what the plan allows. Always ask a new provider: “Are you in-network with my specific plan?” — not just with the insurance company.

Prior authorization (prior auth / pre-auth)

Permission from the insurer before a service happens. Your provider submits an evaluation and a treatment plan; the insurer approves a set number of hours for a set period. Authorizations expire — put the end date in your phone — and approval is permission to proceed, not a guarantee of payment.

Medical necessity

The standard almost every denial turns on: whether the service is clinically required, by the insurer’s written criteria. It’s a documentation question, not a judgment about your child. If you’re denied, ask in writing which criteria were used and which one your child was found not to meet.

Superbill

An itemized receipt from an out-of-network provider containing everything an insurer needs to process a claim: dates of service, procedure (CPT) codes, diagnosis codes, the provider’s credentials and tax ID, and what you paid. You pay the provider, submit the superbill yourself, and get reimbursed at your out-of-network rate — if your plan has one. Just ask: “Do you provide superbills?”

EOB (Explanation of Benefits)

The statement your insurer sends after processing a claim, showing what the provider charged, what the plan allowed, what the plan paid, and what portion is yours. It is a receipt of a decision — a summary of the math. It is not a bill. See the callout below.

Appeal

Your formal request that the insurer reconsider a denial. Every denial notice and EOB must tell you how to appeal and by when — that deadline is real, so note it the day the letter arrives. Appeals succeed regularly, most often when the provider supplies documentation the insurer said was missing.

A worked example

The example plan: premium $400/month · deductible $2,000 · coinsurance 20% after the deductible · out-of-pocket maximum $5,000.

The example care: in-network speech therapy, allowed amount $100 per visit, twice a week.

• Visits 1 through 20. You haven’t met the deductible, so you pay the full allowed amount: $100 each. That’s $2,000, and around week ten your deductible is met.
• Visit 21 onward. Coinsurance kicks in. You pay 20% of $100 = $20 per visit; the plan pays $80.
• A full year — say 100 visits. $2,000 (the deductible) + 80 visits × $20 = $1,600. Your total: $3,600. The plan’s total: $6,400. Combined allowed charges: $10,000.
• The out-of-pocket max never triggers here. $3,600 is under the $5,000 cap — but if a hospital stay or a second therapy landed in the same year, you’d hit $5,000 and then pay nothing more for covered in-network care until the plan year resets.
• Premiums are separate. That $400/month — $4,800 for the year — sits outside all of the math above.

The out-of-network version. Same therapy, but the provider charges $150 while your plan still only allows $100. Your plan may apply a separate, higher out-of-network deductible, reimburse a smaller percentage, and leave you owing the $50 difference on top. That gap is why “are you in-network with my plan?” is the first question you ask a new provider.

When a bill arrives

1. Wait for the EOB before you pay anything

   Providers sometimes bill before the insurer has finished processing. Pay first and you may be paying an amount insurance was about to cover — and getting money back is far harder than never sending it.

2. Put the bill and the EOB side by side, line by line

   Match the date of service, the service or code, and the dollar amount the EOB lists as “patient responsibility.” One row at a time. Most confusion dissolves right here.

3. If they match — pay it

   The number is real. If it’s more than you can pay at once, call the billing office and ask for a payment plan or a financial-hardship policy before the account goes to collections. Ask early; almost everyone says yes.

4. If they don’t match — dispute it, provider first

   Call the provider’s billing office: “My EOB shows my responsibility as $X and this bill says $Y. Can you explain the difference?” Billing errors and wrong codes are common and get fixed at this level every day. If billing insists the bill is right, call the insurer next and ask them to walk you through how the claim was processed.

5. Get it in writing, then appeal formally if you need to

   Log every call — date, name, reference number — and ask for any resolution by email or portal message. If the disagreement is with the insurer, the EOB or denial notice explains how to file a formal appeal and by when. Follow those instructions exactly and keep a copy of everything you send.

Village notes

• Photograph your insurance card, front and back. The number on the back is the one you’ll actually call, and behavioral health often has its own separate line.
• Keep one folder per plan year. EOBs, bills, authorization letters, denials. When something goes wrong in November, the fix usually lives in a February document.
• Denial letters are worth money. Several grant programs fund exactly what insurance refused — and the letter is your proof.
• Ask the billing office before you ask the internet — they often know which single code change unlocks the payment. Then read our private insurance guide for Tennessee’s autism mandate and the fully-insured versus self-funded question.