Insurance 101

Health insurance is vitally important but can also be quite tricky. It is very important to know your insurance benefits and out of pocket costs. It is a good idea for you to check with your insurance company about your benefits. This is the best way to fully understand your health plan.

Here at Aquarius Pediatrics, we verify insurance and get information available to us on what your out of pocket expenses will be prior to your visit. We are happy to review this with you at your visit. We ask for payment of services at time of appointment unless other arrangements have been made.

Here are some terms and definitions that are important in understanding the basics about health insurance, as well as a helpful video.


The amount of money you pay for your care before insurance company shares in the cost. This is paid monthly and may be partly or fully covered by your employer. This usually covers all preventative care such as physicals, well child checks, vaccines and routine lab screenings annually. Depending on the insurance, a well child check may be covered once a year from the last appointment or after the insured’s birthday.


The amount of money you pay before your insurance kicks in to share in the cost.

Copay / Coinsurance

The amount you pay after you have met your deductible. A copay is usually a set amount per visit. Coinsurance is usually a percentage of the cost that you are required to pay.

Out of Pocket Maximum

Once you reach a certain amount paid for healthcare, you will reach a maximum that is required by the insurance company for you to pay. Then the insurance company picks up the rest of the cost.

Every year your deductible and out of pocket maximums start over.


The main difference is that an HMO requires the patient to choose a primary healthcare provider. They usually require the primary provider to send referrals before a specialist can be seen. With a PPO, a primary care provider does not need to be selected and a referral usually does not have to be sent to be seen by a specialist.

Understanding Your Health Insurance Costs