Understanding Your Insurance Plan

02/01/2022 by Sarah Pena

As many of us are still welcoming in 2022, it might mean you have new health insurance coverage for the new calendar year. Lots of employers who provide coverage for their employees will shop around for new plans year after year, to offer more benefits to their employees and to save money on the cost of insuring their staff. But sometimes a change in your insurance plan can be confusing, and that confusion can sometimes mean individuals are under-utilizing their insurance – not taking advantage of the care that is available to them.

At North Country HealthCare, it is our goal to keep you healthy, so you can continue to do the things you love to do and be with the people you love for a long time! Understanding your health insurance is an important part of staying healthy and happy. If you understand what benefits are available to you, how much they cost (or don’t cost!), and how to use them, that may help you keep your wellness top of mind. It will also help you stay on track with the screenings and immunizations that are recommended based on your age, gender, hereditary factors, pre-existing conditions and overall general health.

What We Offer

At North Country HealthCare, we accept most private insurance plans, which includes most employer-sponsored coverage. We also accept AHCCCS (Arizona’s Medicaid program), KidsCare (children’s health insurance plan in Arizona) and Medicare. Our primary care providers offer wellness exams for patients of all ages, and can complete many age-appropriate screenings as well. When your provider recommends a lab test, many of our locations can perform these on-site, or we can refer you to another location close by.

Understanding the Basics

Below is a glossary of commonly used health insurance terms. We hope these definitions will assist you in better understanding your coverage so you can make your health a top priority in 2022!

• Allowed Amount – The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan’s allowed amount, you may have to pay the difference.
• Claim – A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
• Copayment – A fixed amount (for example, $25) you pay for a covered healthcare service, usually when you get the service.
• Coinsurance – Your share of the costs of a covered healthcare service, calculated as a percent (for example, 20%) of the allowed amount for the service.
• Deductible – The amount you owe for healthcare services your health insurance or plan covers before your health insurance or plan begins to pay.
• Explanation of Benefits (EOB) – A summary of healthcare charges that your health plan sends you after you see a provider or get a service. It is not a bill.
• Formulary – A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
• Network – The facilities, providers and suppliers your health insurer or plan has contracted with to provide healthcare services.
• Out-of-Pocket Maximum/Limit – The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. Monthly premiums are NOT included in this amount.
• Premium – The amount that must be paid for your health insurance or plan (usually a monthly payment).
• Qualifying Life Event – A change in your situation — like getting married, having a baby, or losing health coverage — that can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period. This can be for a private (employer) plan or for healthcare.gov.

For more helpful health insurance terms, visit the glossary from the Health Insurance Marketplace: https://www.healthcare.gov/glossary/

Don’t have health insurance? North Country HealthCare has a team of certified application counselors who can help you see what you qualify for and apply for coverage. Visit our Get Covered page to schedule your free enrollment appointment at a location near you!

2 responses to “Understanding Your Insurance Plan”

1. Does Dr Hanny accept a Humana Medicare Advantage Plan?

   Reply

   • Great question KC – I will have a clinic manager email you directly with more information. Thank you for reaching out!

     Reply

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