Health Insurance Terms Explained by a Doctor

Health insurance explained by a doctor: what your premium, deductible, copay, coinsurance, and out-of-pocket maximum actually mean, where your coverage comes from, and what health insurance really costs in 2026. I'm Dr. Nico Munley, an internal medicine physician. In this video, I break down how health insurance works in plain English, walk through a full year of real-world medical bills, and share how I think about insurance as a doctor. IN THIS VIDEO The 5 health insurance terms that decide what you pay Why your premium doesn't count toward your deductible A full-year example: a physical, a sick visit, an MRI and an appendectomy Where health insurance comes from: employer, ACA Marketplace, Medicare, Medicaid, military, and COBRA Average health insurance costs in 2026 How to choose a plan: your best-case year vs. your worst-case year THE 5 HEALTH INSURANCE TERMS YOU NEED TO KNOW Example plan: Alex, 35, on a typical employer plan 1. Premium: $125/month The monthly cost of having insurance, whether you use it or not. 2. Deductible: $2,000 What you pay out of pocket before your plan starts sharing costs. 3. Copay: $30 primary care / $50 specialist A flat fee for each visit. 4. Coinsurance: 20% Your share of the bill after you meet your deductible. The plan pays the other 80%. 5. Out-of-pocket maximum: $5,000 The most you'll pay in a year for covered care in your plan's network. After that, your plan pays 100%. Your premium does NOT count toward your deductible or out-of-pocket maximum. EXAMPLE: ALEX'S YEAR January, annual physical: $0 (preventive care) March, sinus infection visit: $30 copay June, knee MRI ($1,200 negotiated price): Alex pays all $1,200 toward his deductible September, appendicitis (ER, surgery, one night in the hospital, $25,000): Alex pays the last $800 of his deductible, then 20% coinsurance until he hits his $5,000 max October to December, follow-ups and physical therapy: $0 Total: $5,000 out of pocket + $1,500 in premiums = $6,500 for about $28,000 of care. WHERE AMERICANS GET HEALTH INSURANCE (2025) Employer / W-2 benefits: 53.5% Medicare (65+ or certain disabilities): 20.1% Medicaid / CHIP (low income): 17.1% Buying your own plan, including the ACA Marketplace: 10.5% TRICARE (military): 2.8% VA / CHAMPVA: 1.2% Uninsured all year: 7.9% (26.7 million people) People can have more than one type of coverage, so these add up to more than 100%. AVERAGE HEALTH INSURANCE COSTS Employer plan, single (2025): $9,325/year total. Workers pay about $125/month. Average deductible: $1,886. Employer plan, family (2025): $26,993/year total. Workers pay $6,850/year, about $570/month. ACA Marketplace (2026): about $178/month on average after subsidies, up 58% from 2025. Average deductible: $3,786. Medicare (2026): Part B is $202.90/month with a $283 deductible. The Part A hospital deductible is $1,736. Original Medicare has no out-of-pocket max. Medicare Advantage caps in-network costs at up to $9,250. Medicaid: usually $0 premiums. ACA out-of-pocket limit: $10,600 for one person in 2026, rising to $12,000 in 2027. This video is for education only and is not medical, legal or financial advice. Watching does not create a doctor-patient relationship. #HealthInsurance #OpenEnrollment #HealthInsuranceExplained #Deductible #HealthCare