Question: Do I have a choice of pediatric medical subspecialists and pediatric surgical specialists?
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: 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
Question: What is a true emergency?
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: 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: 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.
This information should not be used as a substitute for the information found in your own health insurance plan contract
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