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Health Insurance 101: The Basics (Health Insurance 1/3)
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00:03
Meet Susie.
來認識一下蘇西。
00:04
Susie just graduated from college and got her first job at Corporate Co.
蘇西剛從大學畢業，並在 Corporate Co. 擁有了她的第一份工作。
00:08
The job is great: free food, friendly colleagues, and even a health insurance plan.
這份工作很棒：有免費食物、友善的同事，甚至還有健康保險方案。
00:12
However, there’s just one problem: Susie has no idea what health insurance is, or even if their plan is right for her.
然而，只有一個問題：蘇西完全不了解健康保險是什麼，甚至不知道他們的方案是否適合她。
00:19
What should she do?
她該怎麼辦？
00:21
Well her first step is simple: understand how health insurance works.
嗯，她的第一步很簡單：了解健康保險是如何運作的。
00:26
Like all insurance, in return for a monthly fee called a premium, health insurance reduces the costs associated with a risk, in this case, excessive medical bills due to sickness or injury.
就像所有保險一樣，健康保險透過每月繳納的保費，來降低與風險相關的成本；在這個案例中，風險是指因疾病或受傷而產生的龐大醫療費用。
00:36
However, unlike other forms of insurance, health insurance premiums are unique: they’re only based on a few factors, like age, location, and smoking habits, and not on your health
然而，與其他形式的保險不同，健康保險的保費很獨特：它們只基於少數幾個因素，例如年齡、居住地和吸菸習慣，而不會根據你的健康狀況。
00:46
status. That means if you have a pre-existing health condition, like diabetes or asthma, your insurer cannot raise your rates or deny you coverage.
這意味著，如果你有既存的健康狀況，例如糖尿病或氣喘，你的保險公司不能因此提高你的費率或拒絕承保。
00:55
That is undeniably great for consumer, though health insurance also has a lot of problems, mainly the confusing jumble of terms: HMO, deductibles, the list goes on and on.
對消費者來說，這無疑是個好消息，儘管健康保險也有很多問題，主要是令人困惑的術語大雜燴：HMO、自付額等等，沒完沒了。
01:06
However, Susie shouldn’t worry.
不過，蘇西不必擔心。
01:08
Explained properly, health insurance isn’t actually all that complicated.
如果解釋得當，健康保險其實沒那麼複雜。
01:11
Let’s walk through an example.
讓我們來看一個例子。
01:13
Let’s say Susie has a $200 monthly policy with a $1,000 deductible, 20% coinsurance, and a $5,000 out-of-pocket maximum.
假設蘇西有一份月繳 200 美元的保單，其自付額為 1,000 美元，共同保險比例為 20%，且自付上限為 5,000 美元。
01:21
Let’s also say she recently broke her leg playing soccer and has just been stuck with a $100,000 medical bill.
再假設她最近踢足球時摔斷了腿，收到一張 100,000 美元的醫療帳單。
01:28
Yikes! How much of that enormous bill does she have to pay?
天啊！這筆龐大的帳單，她得付多少錢？
01:32
Let’s start with the deductible first.
我們先從自付額開始。
01:34
A deductible is simply the amount of money Susie must pay each year before her insurer starts paying their share.
自付額很簡單，就是蘇西在保險公司開始支付他們的份額之前，每年必須自己支付的金額。
01:40
Susie’s plan has a $1,000 deductible.
蘇西的方案有 1,000 美元的自付額。
01:43
That means, for a $100,000 medical bill, Susie must pay the first $1,000 herself.
這意味著，對於一張 100,000 美元的醫療帳單，蘇西必須先自行支付前 1,000 美元。
01:48
Then, the remaining $99,000 is split between Susie and her insurer, based on her plan’s coinsurance.
接著，剩下的 99,000 美元會根據 Susie 的保險計劃中的共同保險（coinsurance）條款，在她和保險公司之間分攤。
01:55
Coinsurance is the percentage of costs Susie must meet after her deductible has been met.
共同保險是指在扣除額（deductible）用完後，Susie 必須自行負擔的醫療費用百分比。
02:00
Susie’s plan has 20% coinsurance.
Susie 的保險計劃設有 20% 的共同保險。
02:03
That means for every $4,000 the insurer pays, Susie must pay $1,000.
這意味著每當保險公司支付 4,000 美元時，Susie 就必須支付 1,000 美元。
02:08
This cost-sharing continues until Susie reaches her out-of-pocket maximum.
這種費用分擔會持續進行，直到 Susie 達到她的自付上限（out-of-pocket maximum）為止。
02:12
This is quite literally the maximum amount of medical expenses Susie has to pay each year before her insurer pays the rest.
這字面上就是指 Susie 每年在保險公司開始支付剩餘款項之前，必須自行支付的最高醫療費用金額。
02:18
In this example, Susie’s plan has a $5,000 out-of-pocket maximum, and she’s already spent $1,000 on her deductible and $4,000 on coinsurance.
在這個例子中，Susie 的保險計劃設有 5,000 美元的自付上限，而她已經支付了 1,000 美元的扣除額和 4,000 美元的共同保險費用。
02:28
That means she’s reached her out of pocket maximum, and her insurer will have to cover the rest.
這意味著她已經達到自付上限，保險公司將會支付剩餘的所有費用。
02:33
All in all, Susie only paid $5,000 for a $100,000 medical bill.
總計下來，Susie 只需為 100,000 美元的醫療帳單支付 5,000 美元。
02:38
If Susie didn’t have health insurance, that payment would have been all on her!
如果 Susie 當初沒有購買健康保險，這筆費用就得由她全額負擔！
02:42
Susie is thrilled by this, but also wonders if a similar type of calculation applies to routine services, like doctor's visits or medications.
Susie 對此感到非常高興，但也想知道這類計算方式是否也適用於看醫生或拿藥等例行醫療服務。
02:49
Well, no, as it generally turns out.
事實上，通常並不適用。
02:52
Those routine expenses are instead covered by something called a copay.
這些例行醫療費用通常是由另一種稱為「定額負擔」（copay）的機制來涵蓋。
02:56
A copay is a simply flat fee associated with a specific, routine event, like $25 for a doctor’s visit or a certain prescription drug.
定額負擔是指針對特定的例行醫療事件所收取的一筆固定費用，例如看醫生 25 美元或特定處方藥的費用。
03:05
As for you pay for these services, it couldn’t be easier.
至於支付這些服務費用的方式，更是再簡單不過了。
03:08
Susie will either pay directly at the doctor’s office or just get a bill from them later on.
Susie 可以直接在診所支付，或是事後收到帳單再付款。
03:13
Hopefully, you and Susie now have a better understanding of how health insurance works.
希望您和 Susie 現在對健康保險的運作方式有了更清楚的了解。
03:17
Be sure to watch our next video, which covers everything from HMOs to Gold Plans, and be sure to check out our website, where you can find more educational material and great health insurance plans.
請務必觀看我們的下一部影片，內容涵蓋從 HMO 到黃金計劃（Gold Plans）的所有資訊，並記得查看我們的網站，您可以在那裡找到更多教學資料和優質的健康保險計劃。

Health Insurance 101: The Basics (Health Insurance 1/3)

📝 影片摘要

本單元以角色蘇西的經歷，深入淺出地介紹健康保險的基礎運作原理。課程說明保險的核心概念是透過支付保費來分擔風險，並強調健康保險費率不會因既存疾病而歧視。重點在於解析醫療帳單的處理流程：從自付額（deductible）開始，經由共同保險（coinsurance）分攤，直到達到自付上限（out-of-pocket maximum）為止。此外，影片也區分了重大醫療支出與例行就醫的定額負擔（copay）機制，讓學習者能全面理解健康保險的三大核心費用結構。

📌 重點整理

  • ✓ 健康保險透過每月繳納保費，降低因疾病或受傷產生的龐大醫療風險。
  • ✓ 費率獨特性：基於年齡、居住地與吸菸習慣，不會因健康狀況或既存疾病拒保或漲價。
  • ✓ 自付額（Deductible）：保險公司理賠前，個人每年需先負擔的金額。
  • ✓ 共同保險（Coinsurance）：扣除自付額後，個人需負擔剩餘醫療費用的百分比。
  • ✓ 自付上限（Out-of-pocket maximum）：個人每年最高自付金額，超出部分由保險全額支付。
  • ✓ 定額負擔（Copay）：看醫生或拿藥等例行醫療服務收取的固定費用。
  • ✓ 保險理賠流程：先從自付額開始累計，再依比例分攤，最後觸發理賠上限。
  • ✓ 蘇西的案例：透過 10 萬美元的帳單演練，展示保險如何大幅降低個人負擔。
📖 專有名詞百科 ｜點擊詞彙查看維基百科解釋
保費
premium
保險公司
insurer
承保範圍
coverage
自付額
deductible
共同保險
coinsurance
上限
maximum
例行的
routine
定額負擔
copay
保單
policy
支出
expenses

🔍 自訂查詢

📚 共 10 個重點單字
premium /ˈpriːmiəm/ noun
The amount of money paid for an insurance policy.
保費
📝 例句
"Like all insurance, in return for a monthly fee called a premium, health insurance reduces the costs associated with a risk."
→ 就像所有保險一樣，健康保險以每月繳納的保費來降低與風險相關的成本。
✨ 延伸例句
"She pays a monthly premium of $200 for her health insurance."
→ 她每月支付 200 美元的健康保險保費。
insurer /ɪnˈʃʊrər/ noun
A company that provides insurance.
保險公司
📝 例句
"That means if you have a pre-existing health condition, like diabetes or asthma, your insurer cannot raise your rates or deny you coverage."
→ 這意味著如果你有既存的健康狀況，例如糖尿病或氣喘，你的保險公司不能因此提高你的費率或拒絕承保。
✨ 延伸例句
"The insurer will cover the rest of the bill."
→ 保險公司將支付剩餘的帳單。
coverage /ˈkʌvərɪdʒ/ noun
The amount of protection provided by an insurance policy.
承保範圍；保障
📝 例句
"Your insurer cannot raise your rates or deny you coverage."
→ 你的保險公司不能提高費率或拒絕承保。
✨ 延伸例句
"Make sure you understand what your policy covers."
→ 確保你了解你的保單涵蓋的內容。
deductible /dɪˈdʌktəbl/ noun
The amount you must pay out of pocket before the insurer pays.
自付額
📝 例句
"A deductible is simply the amount of money Susie must pay each year before her insurer starts paying their share."
→ 自付額很簡單，就是蘇西在保險公司開始支付他們的份額之前，每年必須自己支付的金額。
✨ 延伸例句
"My health plan has a $1,000 deductible."
→ 我的健康計畫有 1,000 美元的自付額。
coinsurance /ˌkoʊɪnˈʃʊrəns/ noun
The percentage of costs you pay after meeting your deductible.
共同保險
📝 例句
"Coinsurance is the percentage of costs Susie must meet after her deductible has been met."
→ 共同保險是指在扣除額用完後，Susie 必須自行負擔的醫療費用百分比。
✨ 延伸例句
"We have a 20% coinsurance clause."
→ 我們有 20% 的共同保險條款。
maximum /ˈmæksɪməm/ noun
The upper limit or highest amount allowed.
上限；最大值
📝 例句
"This is quite literally the maximum amount of medical expenses Susie has to pay each year before her insurer pays the rest."
→ 這字面上就是指 Susie 每年在保險公司開始支付剩餘款項之前，必須自行支付的最高醫療費用金額。
✨ 延伸例句
"There is a maximum limit on the policy."
→ 保單上有一個上限。
routine /ruːˈtiːn/ adjective
Done as a regular procedure rather than for a special reason.
例行的；常規的
📝 例句
"Susie also wonders if a similar type of calculation applies to routine services, like doctor's visits or medications."
→ Susie 也想知道這類計算方式是否也適用於看醫生或拿藥等例行醫療服務。
✨ 延伸例句
"A routine check-up is necessary once a year."
→ 每年進行一次例行檢查是必要的。
copay /ˈkoʊpeɪ/ noun
A fixed amount paid for a covered healthcare service.
定額負擔
📝 例句
"A copay is a simply flat fee associated with a specific, routine event."
→ 定額負擔是指針對特定的例行醫療事件所收取的一筆固定費用。
✨ 延伸例句
"The copay for a specialist visit is $50."
→ 看專科醫生的定額負擔是 50 美元。
policy /ˈpɒləsi/ noun
A contract with an insurance company.
保單；保險契約
📝 例句
"Let’s say Susie has a $200 monthly policy with a $1,000 deductible."
→ 假設蘇西有一份月繳 200 美元的保單，其自付額為 1,000 美元。
✨ 延伸例句
"You should read the policy carefully before signing."
→ 簽署前你應該仔細閱讀保單。
expenses /ɪkˈspɛnsɪz/ noun
The cost incurred for something.
支出；費用
📝 例句
"Those routine expenses are instead covered by something called a copay."
→ 那些例行醫療費用則是由另一種稱為「定額負擔」的機制來涵蓋。
✨ 延伸例句
"Medical expenses can be very high without insurance."
→ 沒有保險的話，醫療費用可能會非常高。
🎯 共 10 題測驗

1 What factors determine health insurance premiums according to the video? 根據影片，什麼因素決定健康保險的保費？ What factors determine health insurance premiums according to the video?

根據影片，什麼因素決定健康保險的保費？

✅ 正確！ ❌ 錯誤，正確答案是 B

The video states that health insurance premiums are based on age, location, and smoking habits, not health status.

影片指出健康保險保費是基於年齡、居住地和吸菸習慣，而非健康狀況。

2 If Susie has a $100,000 bill and a $1,000 deductible, how much does she pay first? 如果 Susie 有一張 100,000 美元的帳單和 1,000 美元的自付額，她首先需要支付多少？ If Susie has a $100,000 bill and a $1,000 deductible, how much does she pay first?

如果 Susie 有一張 100,000 美元的帳單和 1,000 美元的自付額，她首先需要支付多少？

✅ 正確！ ❌ 錯誤，正確答案是 C

Susie must pay the deductible amount of $1,000 before the insurer starts paying.

Susie 必須先支付 1,000 美元的自付額，保險公司才會開始支付。

3 What does 'coinsurance' mean in the video? 影片中「共同保險」（coinsurance）的意思是什麼？ What does 'coinsurance' mean in the video?

影片中「共同保險」（coinsurance）的意思是什麼？

✅ 正確！ ❌ 錯誤，正確答案是 C

Coinsurance is the percentage of costs Susie must meet after her deductible has been met.

共同保險是指在扣除額用完後，Susie 必須自行負擔的醫療費用百分比。

4 What is the 'out-of-pocket maximum'? 什麼是「自付上限」（out-of-pocket maximum）？ What is the 'out-of-pocket maximum'?

什麼是「自付上限」（out-of-pocket maximum）？

✅ 正確！ ❌ 錯誤，正確答案是 B

It is the maximum amount of medical expenses Susie has to pay each year before her insurer pays the rest.

這是 Susie 每年在保險公司開始支付剩餘款項之前，必須自行支付的最高醫療費用金額。

5 What mechanism covers routine expenses like doctor's visits? 什麼機制涵蓋像看醫生這樣的例行醫療費用？ What mechanism covers routine expenses like doctor's visits?

什麼機制涵蓋像看醫生這樣的例行醫療費用？

✅ 正確！ ❌ 錯誤，正確答案是 D

Routine expenses are covered by a copay, which is a flat fee for specific events.

例行醫療費用由定額負擔（copay）涵蓋，這是針對特定事件的固定費用。

6 How much did Susie pay in total for her $100,000 medical bill? Susie 為她 100,000 美元的醫療帳單總共支付了多少錢？ How much did Susie pay in total for her $100,000 medical bill?

Susie 為她 100,000 美元的醫療帳單總共支付了多少錢？

✅ 正確！ ❌ 錯誤，正確答案是 C

Susie paid $1,000 (deductible) + $4,000 (coinsurance) = $5,000 total.

Susie 支付了 1,000 美元（自付額）+ 4,000 美元（共同保險）= 總共 5,000 美元。

7 Can insurance companies deny coverage based on pre-existing conditions? 保險公司可以因為既存疾病而拒絕承保嗎？ Can insurance companies deny coverage based on pre-existing conditions?

保險公司可以因為既存疾病而拒絕承保嗎？

✅ 正確！ ❌ 錯誤，正確答案是 B

The video states that insurers cannot raise rates or deny coverage based on pre-existing conditions.

影片指出保險公司不能因既存疾病提高費率或拒絕承保。

8 What happens after Susie reaches her out-of-pocket maximum? Susie 達到自付上限後會發生什麼事？ What happens after Susie reaches her out-of-pocket maximum?

Susie 達到自付上限後會發生什麼事？

✅ 正確！ ❌ 錯誤，正確答案是 B

Once the maximum is reached, the insurer covers the rest of the costs.

一旦達到上限，保險公司會支付剩餘的所有費用。

9 What is the primary purpose of health insurance? 健康保險的主要目的是什麼？ What is the primary purpose of health insurance?

健康保險的主要目的是什麼？

✅ 正確！ ❌ 錯誤，正確答案是 B

Health insurance reduces the costs associated with risks like sickness or injury.

健康保險降低與疾病或受傷等風險相關的成本。

10 What is a 'flat fee' associated with routine events called? 與例行事件相關的「固定費用」被稱為什麼？ What is a 'flat fee' associated with routine events called?

與例行事件相關的「固定費用」被稱為什麼？

✅ 正確！ ❌ 錯誤，正確答案是 C

A copay is a flat fee for a specific, routine event.

定額負擔（Copay）是針對特定例行事件的固定費用。

測驗完成！得分： / 10

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