Linkage With Other Child and Family Services
Question: 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: 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
Question: Will I have to pay for services provided by my plan?
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 percent 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
Question: Will my health care be paid for if I'm out of town?
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
Question: Where can I learn about the details of my managed care plan?
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. Do not assume that a service will be covered. Be certain it will.
Question: 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: 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.
This information should not be used as a substitute for the information found in your own health insurance plan contract.
Related Articles
