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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Sign in for your plan details

Get personalized information and help

  • View all your benefits
  • Find providers in your network
  • Download your ID card
  • Get quick answers to your questions and more
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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
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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.

Do I need approval before getting care or supplies?

It depends. We've broken down what you need to know when you need approval (prior authorization) before getting care or supplies and how to request it.

Can I request an exception to cover a drug not on Medica's List of Covered drugs?

Yes, here's how and when you can request an exception to your prescription drug coverage.

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.

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. 

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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.

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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.

I overpaid my premium. Can I get a refund?

Our goal is to bill you the correct amount each month. But if you're overbilled and pay too much or make a duplicate payment, you have the right to a refund.

What happens if I don't pay my premium on time? 

Like other bills, you need to pay your premium on time each month. If not, your coverage could end. Your premium is due by the first of each month. If your premium is late, you'll have some time to pay the past due amount before your coverage ends. This is called a grace period*

Why are you requesting money back from a claim that's already been paid?

Sometimes we may deny a claim after we've paid it and request the money back from the provider. This is known as a retroactive denial. If we deny a past claim, you may be responsible for the cost.

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. Check out this PDF for all the details.

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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.

What does coordination of benefits mean?

If you’re insured by more than one health plan, we’ll determine what portion of your claims we’ll pay and what your other plan should pay. If you have another plan, fill out this form so we can coordinate your benefits. 

Who can I contact with questions?
We’re here to answer any questions you might have. Just give us a call. 

General Contact

Monday to Thursday, 8 a.m. to 5 p.m. CT
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.
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First-time coverage

Shopping for health care coverage for the first time doesn’t have to be scary. We can help you navigate 
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Starting a new family

Make sure to protect your loved ones with a health care plan.

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Self-employed

We can take the mystery out of buying insurance, so you can get back to running your business.
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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.
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