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Individual + family plan FAQs
Get answers to common questions about health insurance plans for individuals and families. Find out about benefits, coverage, financial information, and more.
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Plan overview
A health plan is insurance that protects you against the potentially high costs of medical care and prescription drugs. With health insurance, you’ll have a limit on your health care costs for covered services and supplies. Plus, you’ll get discounted fees from doctors, clinics, and hospitals.
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Resources
When it comes to individual and family health plans, there's a lot to consider. We've pulled together all our resources in one place to help you figure out:
- How insurance works
- Coverage and benefits
- Plan Types
- Enrollment periods
- Subsidies
- Helpful terms
Getting care
Is my doctor covered by my plan?
You can search for the doctors, specialists, and other providers covered by your specific plan.
What care options do I have?
Check out the programs and services covered by your specific plan.
Should I go to urgent care or the emergency room?
You’ll have to decide based on how you’re feeling. We can make that choice a little easier.
Is my prescription medication covered?
Medication coverage varies by plans. Sign in to review the list of drugs covered by your plan.
Why do I need to stay in network?
Every health plan has a network of providers, clinics, pharmacies, and hospitals. When you pick a plan, you’re choosing your network. Your coverage depends on your provider being in your network.
Note: If you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you’re protected from surprise or balance billing. Read your rights.
How do tiered networks work?
Some of our individual and family plans have three tiers of network providers. You’ll receive different levels of coverage based on your provider’s tier.
What type of wellness programs are offered by Medica?
Sign in to see which wellness programs are offered for your specific plan. Or view our general wellness offerings.
What is the Important Information Guide? Why should I use it?
This booklet includes important information to help you decide how to best use your health insurance benefits and how to file a complaint or appeal, if you need to.
Benefits + coverage
How can I find my benefits?
What’s an Explanation of Benefits (EOB)?
It’s a document that explains who, when, and how much you may need to pay for health care services. It’s not a bill, but it does include a summary of services you received and how your plan covers them.
What’s my Summary of Benefits and Coverage (SBC) document?
It provides an overview of important information about your plan’s benefits and coverage.
Financial
What’s the difference between a deductible, copay, and coinsurance?
Your deductible is the amount you pay each year before your insurance starts to pay. A copay is flat fee you pay for some services and prescriptions. Copays apply to your out-of-pocket maximum, not the deductible. Coinsurance is a percentage of the charges for a health care service that you pay.
How do I read the invoice for my premium?
We’ve broken down all the parts of your invoice to make it easy.
How do I make a premium payment?
You can make payments online.
How do I file a claim?
The process can vary depending on your provider’s networks status and the type of claim you’re filing. You typically won’t have to file a claim — providers usually do it. But if you ever need to file one, we’ve made it easy to figure out how to do it.
Can I get financial assistance to help pay for my insurance?
Many people who buy individual insurance can get a subsidy to help pay premiums and out-of-pocket costs. To get a subsidy, you have to buy your plan through your state's health insurance marketplace.
Additional plan details
How does my Member ID card work?
Here’s how to understand all the parts of your ID card.
How do I get forms related to my plan?
We’ve pulled all our forms together to help you find what you need.
Who can I contact with questions?
We’re here to answer any questions you might have. Just give us a call.
What is an Arizona state appeals packet?
Every state has unique rules about how you can file a health insurance claim appeal. If you live in Arizona, this packet explains everything you'll need to know such as, who can file an appeal, how to send it in, and how long a health insurance company has to make a decision.
Where can I see my pharmacy claims?
In your member portal, you'll find a summary in "Claims Overview" under "Claims" in the navigation. To view details of a specific claim, click on the claim number. If your claim information isn't immediately available, keep in mind it takes time for a claim to arrive from your provider, be processed, and show up in your member website.
What does the status of my pharmacy claim in my member portal mean?
As you're reviewing your "Claims Overview," keep in mind current status will be shown. Claim history is not shown. You can find more detailed claim information at Express Scripts®.
General Contact
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Friday, 10 a.m. to 5 p.m. CT
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Information to help you
We get it. There’s a lot to think about when it comes to health insurance plans. We’ll help you figure it all out.
Health plan info guides
What you need to know about coverage at key points in your life.
First-time coverage
Shopping for health care coverage for the first time doesn’t have to be scary. We can help you navigate
Self-employed
We can take the mystery out of buying insurance, so you can get back to running your business.
Early retirement
You’re ready to exit the workforce and step into retirement. Find a plan that helps you stay healthy for years to come.