Once you understand how these four work — and how they interact — you can read any plan summary and know what you're actually buying.
The fixed amount paid every month to keep coverage active — whether or not anyone uses care. Usually split between the employer and the employee.
What you pay out of pocket for covered care before the plan starts chipping in. Preventive care is typically free before the deductible.
A flat dollar amount for a specific service — a doctor visit, a prescription. Predictable, and on many plans it applies even before the deductible is met.
After the deductible is met, you and the plan split costs by percentage. "80/20" means the plan pays 80%, you pay 20% — until you hit your out-of-pocket max.
This is the part most people never get explained: the order things happen in when you actually use your plan. Say you have a $2,000 deductible, 20% coinsurance, and a $6,000 out-of-pocket max.
Every month, in the background, regardless of whether you see a doctor. This never stops and never counts toward your deductible or out-of-pocket max.
A $10,000 surgery arrives. You pay the first $2,000 (your deductible) out of pocket. The plan hasn't started its share yet.
On the remaining $8,000, your 20% coinsurance applies. You pay $1,600; the plan pays $6,400. So far you're out $2,000 + $1,600 = $3,600.
If more bills push your total spending to $6,000 for the year, you're done — the plan pays 100% of covered care after that. The out-of-pocket max is the worst-case number that matters most.
No textbook definitions — just what each one means for your wallet.
The most you'll pay for covered in-network care in a year. Once deductible + copays + coinsurance reach it, the plan covers 100%. Premiums don't count toward it.
The doctors, hospitals, and pharmacies your plan has negotiated rates with. In-network care is cheaper; out-of-network can cost far more or not be covered at all.
How the monthly premium is split between employer and employee. A common setup is the employer covering a large share of the employee's premium and less of dependents'.
The plan's list of covered prescription drugs, sorted into tiers. Lower tiers (generics) cost less; specialty drugs sit in higher tiers with bigger copays or coinsurance.
Routine checkups, screenings, and vaccines. By law these are typically covered at 100% in-network — before you've touched your deductible.
A High-Deductible Health Plan: lower premiums, higher deductible. Often paired with an HSA. Good for healthier groups comfortable trading a higher deductible for lower monthly cost.
Explanation of Benefits — the statement showing what a provider billed, what the plan paid, and what you owe. It's not a bill; it's the receipt of how a claim was processed.
Who's on the plan: employee only, employee + spouse, employee + child(ren), or family. Each tier has its own premium — family coverage costs more than employee-only.
Three ways to pay for care with pre-tax dollars. They sound alike but behave very differently on ownership, rollover, and who funds them.
| HSA | FSA | HRA | |
|---|---|---|---|
| Full name | Health Savings Account | Flexible Spending Account | Health Reimbursement Arrangement |
| Who funds it | Employee and/or employer | Mostly employee (pre-tax payroll) | Employer only |
| Requires an HDHP? | Yes | No | No |
| Who owns it | The employee — it's theirs to keep | The employer (use-it-or-lose-it) | The employer |
| Rolls over year to year? | Yes — balance grows, can invest it | Limited — small carryover or grace period | Depends on plan design |
| Best for | Saving long-term while on an HDHP | Predictable yearly expenses | Employers wanting to control reimbursement |
This is the structural decision behind your plan — who carries the risk when claims come in. It's where a good broker earns their keep, because the right answer depends on your group's size and health.
You pay a fixed monthly premium and the carrier takes on all the risk. If your team has a heavy claims year, that's the carrier's problem — your cost is locked for the plan year.
You pay a steady monthly amount covering expected claims, admin, and stop-loss protection. If claims come in low, you may get money back at year-end. Predictable like fully insured, with upside.
You pay employees' claims directly and keep what you don't spend — with stop-loss insurance capping your downside. More risk and more administration, but maximum control and transparency.
There's also ICHRA (Individual Coverage HRA) — a newer model where you reimburse employees tax-free for individual plans they choose themselves. It's growing fast as a flexible alternative, and it's something we help design. Not sure which fits? That's exactly the conversation we have for free.
The cheapest premium isn't always the cheapest plan. Enter up to three options, pick how much care you expect to use, and see your estimated total cost for the year — premiums and out-of-pocket combined.
"Other medical costs" covers everything beyond the visits and generics above — urgent care, ER, labs, imaging, outpatient procedures, hospital stays, surgeries, and specialty drugs. Enter the full price before insurance; the calculator runs it through each plan's deductible and coinsurance for you.
You understand the pieces — we'll shop the carriers, run the comparison, and rank your options by value. No cost for our brokerage services, no pressure.