How to Use Your Managed Care Plan Effectively:
Questions and Answers for Families With Children

Many changes have and will continue to occur in how your family will receive health services. One important change is the use of managed care plans, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), by employers and state Medicaid agencies. Managed care plans are different than traditional "fee-for-service" plans in two major ways:

1. Networks limit the number of doctors who are part of their plans. Few doctors and hospitals are part of all HMO or PPO plans. This is why it is very important for you to know which plans include - your pediatrician, pediatric medical subspecialist, and pediatric surgical specialist or which plans your pediatrician, pediatric medical subspecialist, or pediatric surgical specialist has chosen to join.
   
   
2. Managed care plans try to keep costs down by requiring your doctor to take more control over the types of health care services you receive. For example, your doctor may need to give his or her approval before you can see a pediatric medical subspecialist and/or pediatric surgical specialist, choose a hospital, or receive emergency services.

So that families are more informed about managed care plans, the American Academy of Pediatrics has prepared this list of commonly asked questions. The questions cover such topics as pediatric primary and pediatric medical subspecialty and/or pediatric surgical specialty services that need prior approval, and cost-sharing requirements. Health care can be complicated, but you do have rights. The rights you have depend on how you get your coverage, the type of plan you have (HMO, PPO, Point of Service/POS) and the State in which you live. You can get information about agencies in your state that can help you resolve a problem you may be having by visiting www.healthinsuranceinfo.net or by obtaining general consumer information on health insurance at www.healthcarecoach.com.

This brochure should not be used as a substitute for the information found in your own health insurance plan contract. Click on the general area below to access questions and answers about that topic:

• Primary Care
• Specialty Care
• Emergency Care
• Hospital Care
• Services Requiring Prior Approval
• Complaints, Claim Denials, and Appeals
• Linkage with Other Child and Family Services
• Cost Sharing Requirements
• Out of Area Services
• Exclusions and Limitations

Primary Care

Answer: It is recommended that you choose a pediatrician as your child's primary care doctor. A pediatrician has years of training and experience in children's health care. If your pediatrician is not in the plan, you can ask the plan to include him or her. If you go to a pediatrician who is not in the plan, your plan may not fully or even partially pay for your care. Ask your pediatrician which plans he or she is in and try to join one of those plans. Before choosing a plan, you also should think about the hospitals to which your pediatrician is able to admit patients and pediatric medical subspecialists and/or pediatric surgical specialists to whom he or she refers. If you don't have a pediatrician, ask your managed care plan for a current list of pediatricians whose practices are open to new patients.

Question 2: What is my pediatrician's role in managed care?

Answer: A pediatrician provides primary care for newborns, infants, children, adolescents, and young adults through age 21. As a primary care doctor, he or she provides preventive care, takes care of illnesses and injuries, and diagnoses and treats acute and chronic disorders. A pediatrician makes referrals to pediatric medical subspecialists and/or pediatric surgical specialists when needed and coordinates other services for the total care of your child. Your plan may require that your pediatrician serve as a "gatekeeper" to authorize or approve certain services. Without these approvals, you may have to pay for part or all of these services yourself.

Question 3: What if I want to change doctors?

Answer: Finding a pediatrician who meets your family's needs is important. It is also best to stay with that pediatrician once you have made your choice. However, situations change and you may need to choose a new pediatrician. All plans allow you to choose another doctor from those participating in the plan. Check with your plan to get information on how to do this. You must let your plan know if you change your pediatrician. Some plans only allow you to change doctors during a specific period of time.

Question 4: How is primary care covered?

Answer: Managed care plans usually pay for primary and preventive care visits, including well child checkups, immunizations, and care for illnesses or injuries. Many plans require families to pay a share of their primary care services, such as $5 to $20 for each visit to the doctor. Remember to bring your insurance card with you to each visit.

Specialty Care

Answer: Work with your pediatrician to choose a pediatric medical subspecialist and/or pediatric surgical specialist in your plan. It is important not to see a pediatric medical subspecialist and/or pediatric surgical specialist without the approval from your pediatrician, otherwise you may have to pay for these services yourself. If you decide to use a pediatric medical subspecialist and/or pediatric surgical specialist who is not in your plan, check your contract for details about whether you or your plan will pay for the care and how much it will cost.

Question 6: Who decides if certain care is "medically necessary"?

Answer: Usually, a managed care plan relies on the primary care doctor to determine if a service is medically necessary. However, the plan may limit the pediatrician's options by having a specific list of treatments that are approved for certain illnesses.

Emergency Care

Answer: Most plans define a true medical emergency as a sudden, unexplained, or possibly life-threatening medical situation or a very severe illness or injury for which you do not have time to call your pediatrician. Most managed care plans will pay for emergency room care in a true emergency. Follow-up care (such as removing stitches) should be done in your pediatrician's office. Managed care plans will not pay for follow-up care done in the emergency room.

Question 8: Where can I take my child in a true emergency?

Answer: Find out which hospitals participate in your plan so you are prepared for an emergency. In a life-threatening emergency, go to the nearest hospital. Most plans will pay for after-hours emergency room care at a hospital that is not in your plan only if it is a true emergency. If you use a non-participating hospital for an illness or injury that requires immediate medical attention, but is not life-threatening, you may have to pay for these services yourself.

Question 9: Will my plan pay for after-hours coverage?

Answer: Plans vary on how they provide after-hours care. Check ahead of time with your pediatrician or managed care plan. If your child is sick or injured, you should call your pediatrician or the person on call for advice. Someone will talk to you about the problem and may give you advice over the phone, see your child, or refer you and your child to an after-hours facility.

Hospital Care

Answer: Work with your pediatrician to choose a hospital in your plan that specializes in the care of children. If your plan does not include one, talk to your pediatrician about what arrangements will be made if and when your child requires care at a hospital that does specialize in children. If you go to a hospital that is not in your plan without prior approval, you may have to pay for part or all of the cost of those services.

Question 11: What hospital services require prior approval?

Answer: Most hospital procedures and surgeries, both outpatient and inpatient, require prior approval. Also, your plan may require that certain procedures and surgeries be done on an outpatient basis in order to be paid for by the plan. For inpatient hospital care, managed care plans often limit the number of days they will pay for your child to stay in the hospital. Coverage for longer stays requires approval by the managed care plan. Without such approval, you may be responsible for part or all of the hospital and physician charges.

Services Requiring Prior Approval

Answer: In addition to hospital admission and emergency room services, high-risk or high-cost services usually need prior approval. These may include:

• CT scans
• Magnetic resonance imaging (MRI)
• Nuclear medicine studies
• Pulmonary function tests
• Ultrasound
• Consultation with pediatric medical subspecialists and/or pediatric surgical specialists

Answer: You must get prior approval from your pediatrician or your plan, whether for pediatric medical subspecialty care, pediatric surgical specialty care, or hospital services.

Question 14: When is a second opinion required?

Answer: Some plans require a second opinion from another doctor before approving certain types of care. Your plan is likely to require this second opinion from another doctor in your plan. This doctor may or may not be a pediatrician or pediatric medical subspecialist and/or pediatric surgical specialist.

Complaints, Claim Denials, and Appeals.

Question 15: How do I file a complaint if I am not satisfied with the services my child has received?

Answer: First, talk with your pediatrician about your concerns, no matter who provided the services. A partnership based on open and honest communication is very important to meeting your child's health care needs. This can often reduce the number of problems you may have in making your managed care plan work for your family. If you feel you need to file a complaint, call or write to the member service representative of your plan. See your plan handbook for information about filing a complaint. You also can contact your employee benefits manager for help.

Question 16: What options do I have when a claim is denied?

Answer: Managed care plans have specific procedures about denials of claims and appeals. Typically, your plan will let you know in writing if a service is denied. You may request a review of the denial by filing a written request with your plan, typically within 30 days after the denial notice. If you write an appeal letter, include additional reasons why the service was needed. A decision will be made about your appeal, usually within 30 to 90 days of the request. If you are still dissatisfied, you may want to contact the office of your state insurance commissioner to see if it can help. As a final step, you can take legal action. The best way to avoid problems is to know and understand your plan before you or your employer sign up with it.

Linkage With Other Child and Family Services

Question 17: What if my plan denies the appeal?

Answer: Many states, though not all, offer consumers an opportunity to have decisions to delay or deny health care reviewed by organizations that are not connected to their health plans. This process is often called "Independent Medical Review" or "External Review". If your state has a program for reviewing health plan decisions, you will need to file a request with that agency. Each state has an agency that oversees health plans and health insurance companies. Sometimes this agency is the department of insurance or department of health. They find out which agency oversees health care insurance issues in your state, visit www.healthinsuranceinfo.net

Question 18: Can I see doctors and other providers not participating in my health plan?

Answer: While it is possible to get a referral outside of your plan, managed care plans don't like to approve care from out-of-plan doctors or other providers, such as clinical psychologists, physical therapists, etc. You may need to pay for all or some of the charges by an out-of-plan provider. Check your plan for details. There are preferred provider organizations (PPOs) that enable you to see providers outside of your plan, but additional fees will be required.

Question 19: Are there additional health programs that serve children with special health care needs?

Answer: Several programs are available in your state to help families who have children with special health care needs. These include:

• Medicaid, a public insurance program for poor and disabled children and adults;
• Help for children with special health care needs available through state programs, usually located in the state health department;
• Early intervention and special education programs, available in local school districts and communities.

Ask your pediatrician for more information about these and other programs.

Cost Sharing Requirements

Answer: You may have to pay for part or all emergency services for non-emergency problems. Your plan may require you to pay before the plan begins to pay. This is called a deductible (eg, $500 per year). Plans also may charge a deductible for certain services (eg, $100 for a hospital stay). You also may need to pay a portion of each visit called a copayment (eg, $10). Some plans require you to pay part of each service as a coinsurance (eg, 20% of the cost of a blood test). You may have a copayment for emergency room services. Children's preventive services, such as well-child checkups and immunizations, may or may not be covered without cost sharing. You should carefully review your plan's benefit description for details. The best time to review a plan is before you sign up with it. Before visiting your doctor, check the accepted methods of payment for your out-of-pocket expenses. Options for payment may include cash, check, or credit card. Remember to bring your insurance card with you to each visit.

Out-of-Area Services

Answer: Health care for serious problems that are covered by your plan will most likely be paid for. True emergencies will be covered, as outlined in questions 8 and 9. Elective services will probably not be covered. You should check with your managed care plan for details, such as whether you need prior approval from your pediatrician for acute but not emergency medical care. Exemptions may be made for college students.

Exclusions and Limitations

Answer: Ask for and carefully read your plan's written policies. The policies describing the details of your plan are often called a certificate of coverage. All managed care plans are required to prepare materials that are clearly written and comprehensive. If you have questions, talk to a representative of the plan. If your plan is through your employer, talk to the personnel or benefits manager. Services covered by the plan may change periodically, such from one benefit plan year to another. Review your plan at least annually. Do not assume that a service will be covered. Be certain it will.

Question 23: What services typically are not paid for in managed care plans?

Answer: Check your plan for specifics. Look for the sections describing "exclusions" or "limitations." Services that are often excluded are the following:

• Experimental or investigational services
• Cosmetic services
• Custodial care
• Blood products
• Glasses and contact lenses
• Certain organ transplants

Many managed care plans also have general exclusions, such as services or supplies that are not medically necessary or for which there are no accepted standards of medical practice.

Question 24: Are there limits on what the plan will pay for?

Answer: All plans limit some services, such as mental health care and home health care. If your child needs services that are limited by your plan, you should seek advice from your pediatrician.

The recommendations of this publication are provided as a source of information. Variations, taking into account individual circumstances, may be appropriate.