Financial Matters

Your Healthcare Coverage

How to Evaluate Your Insurance Coverage or Choose a New Plan

One of the most important responsibilities of parenthood is making certain that your child's healthcare needs are met. Here is some information to help you understand your healthcare coverage or choose a new plan.

What Services Should a Healthcare Plan Cover?

Ideally, a health plan for children should include the services in the Health Plan Checklist from birth through age 21. However, most plans do not cover them all, so it's important to compare plans and choose the one that most closely fits your child's needs.

How Do I Compare Healthcare Plans?

Have written information about each plan you wish to compare. Then, for each, make sure you understand:

• The services covered (use checklist below).
• Limitations on the number of times you can use each service.
• Limits on the length of time you can use each service.
• Expenses you must pay, such as monthly payments, co-insurance, co-payments and deductibles.
• Also, make a list of services your child has needed over the past year and ask your doctor about care that may be needed in the future. Compare these services with those that your plan or prospective plan offers. Also, think about the unexpected. You'll appreciate the security of knowing that care is available if it is needed.

What Questions Should I Ask?

Many of your questions can be answered by reading plan-related literature. However, if you have questions, ask!

Ask your child's doctor:

• Do you participate in the plan my family is considering? If so, are you planning to discontinue your participation in the near future?
• Do you know if physicians you refer patients to participate?
• What do you think about the services and benefits offered by each plan?
• If my child needs hospitalization, are you allowed to send him or her to a children's hospital? If you need to refer my child to a specialist, must the plan approve? If so, how long does this usually take?

How to ask: call the office, explain your reason for calling and ask when the doctor can spend a few minutes answering your questions.

Ask your employee benefits manager:

• When will my coverage begin?
• Is there anything in this plan about pre-existing conditions?
• Are there restrictions on which doctors and hospitals I can use? If so, which providers are under contract with this plan?
• If the healthcare plan covers a service, but I have to get that service from a provider who is not on the plan's approved list, will the bill be paid at a lower rate? Can the health plan refuse to pay the bill?
• At what age and under what conditions will my child's coverage end?
• If my child is born with a birth defect or other complication, can the plan refuse coverage?
• Is my child's doctor on your approved list? If not, will I be required to change doctors? If so, can the doctor I choose be a primary care pediatrician?
• Can my child's doctor be put on your approved list?
• If my child needs to see a specialist, where can we be referred for care? Are there any conditions that must be met? Will my primary care doctor have to fill out forms?
• Does my child's doctor have the final say in referring my child to a specialist? If not, can we appeal negative decisions?
• If a pediatric specialist has been treating my child for a condition such as asthma or diabetes, will you allow us to stay with this specialist?
• If my child needs the services of a children's hospital, will you cover all of these services? If not which services will be covered and how is this decision made?
• Will you cover routine services performed at a children's hospital, such as hernia repair, tonsillectomy, asthma or allergy treatment?
• Must I get an okay from the plan before my child can get services or treatment covered by the plan?
• What rules do you have about emergency, after-hours and out-of-town care?

How to ask: Most health plans have a toll-free subscriber number. You will probably find it printed on any literature that you receive.

You can also ask you family, co-workers and friends about their coverage.

Or, you can ask us about your insurance coverage: call 1-800-TRY CHOP

Healthcare Plan Checklist

Preventive and primary care: the "basics"

	Immunizations (shots)
	Routine check-ups
	Doctor visits during illness
	Speech, hearing and vision testing
	Dental check-ups
	Laboratory and X-ray services
	Prescription drugs
	Health education
	Family planning
	Pregnancy and childbirth services

Major Medical Services

Children have unique healthcare needs. Their bodies are different and so are their healthcare needs. Children should be cared for by doctors and healthcare providers who understand these important differences.

• Consultation with a doctor who specializes in the care of children
• Hospital services in a children's hospital, if needed
• Diagnostic services: X-rays, lab tests and other studies done by those who specialize in evaluating children
• Ambulance services

Special Care

• Rehabilitation therapy: speech, occupational and physical therapy
• Equipment and supplies: such as orthopaedic devices, eyeglasses and hearing aides
• Home care (nursing, home IV therapy medical equipment and supplies) or back up to support parents with a seriously ill child
• Long-term care facility services for children who cannot be cared for at home
• Ongoing coordination of care for disabled or chronically ill children
• Hospice care for terminally ill children
• Counseling for emotional problems
• Substance abuse treatment

Know These Terms

Co-payment: The out-of-pocket expenses you are expected to pay, such as $10 for a doctor's office visit or $5 for a prescription.

Deductible: The amount of money you must pay each year before the plan begins to pay some of your medical bills. Deductibles for family coverage are often $200 to $500 per year.

Co-insurance: The percentage of your medical bills you are expected to pay. For example, you may have to pay 20 percent of your bills and the plan pays the other 80 percent.