Insurance soup: understanding your health plan


By Veronica Galas | RN, BSN Carson City Health and Human Services

This column appears in the Nevada Appeal Wednesday health pages. It addresses topics related to the health of our community.

Understanding health insurance can feel like a huge task. It is an alphabet soup of terms – PPO, HMO, plan year, in-network, out of network, deductible, copayment, co-insurance, out-of-pocket maximum, and explanation of benefits (EOB).

Here are some definitions to start with: A plan year is the beginning and end date of a coverage period. This is usually a year-long, but may or may not follow a calendar year. A deductible is the amount you owe for health services before your health insurance starts to pay. An in-network provider is in contract with your insurance company for payment. It will cost you more to get medical services from a doctor or facility that is not on your insurance’s approved list. A copay is the amount you will need to pay at the time you seek medical care, lab work or pick up a medication from a pharmacy.

The Centers for Medicare and Medicaid provides two tools that can help people understand these abbreviations and words: A Roadmap to Better Care and a Healthier You; and A Roadmap to Behavioral Health: A guide to using Mental Health and Substance Use Disorder Services.   Information in these tools is for people who use Medicaid, Medicare, or private insurance. These two tools can be found at

Helpful tips:

Create a health booklet that includes contact information for all of your doctors. Also, include information about your past illnesses, current medicines (including vitamins and herbs), history of vaccinations or shots that you have received, and most recent lab or other health test results.

Know where to seek care – visits to your doctor’s office, an urgent care, or an emergency room have very different wait times, costs, and follow up steps.   Become familiar with the doctors, hospitals, laboratory or testing centers your insurance plan likes.   Oftentimes a lower payment will be due if you go to one of the places your insurance likes. When in doubt, contact your health insurance plan to see what costs are covered and where medical cost may be lower for you.

When you see a special healthcare doctor (specialist) or need a special medical test or procedure, it is possible you will need to get permission from your insurance plan ahead of time. Always ask if you need this approval.   If you do not, your insurance may pay little or nothing for the care you receive. You would then have to pay the entire bill.

Prevention goes a long way. Most insurance plans cover shots, yearly check-ups for women, and other prevention programs at no cost to you.   Call your insurance company to find out what prevention services come at no cost to you.

Finally, Carson City Health and Human Services is partnering with the Division of Welfare and Supportive Services.   Through this partnership, a staff member is available to enroll qualifying individuals and families into Medicaid and Nevada’s Supplemental Nutrition Assistance Program (SNAP). Stop by our facility located at 900 East Long Street each Monday, Wednesday and Thursday for help or more information.

For more information about services and programs available to you, through Carson City Health and Human Services, please visit our website at, follow us on Facebook, or call us at (775) 887-2190. You can also find us at 900 East Long Street in Carson City.