Understanding Your Health Insurance Plan
There are hundreds of health insurance plans, and each one is different. These are some of the things you should know about your plan before scheduling services at The Children’s Hospital of Philadelphia or at a location within the CHOP Care Network.
- The services covered.
- The participating healthcare providers and locations covered.
- Limits on the number of times certain services are covered and the length of time you can use each service.
- Cost-sharing, such as co-insurance, co-payments and deductibles. Your plan may pay differently for certain CHOP services (such as labs and radiology) or certain CHOP locations, which may affect your financial responsibility.
- Coverage of inpatient care (for example, hospitalization after an emergency visit) versus outpatient care (for example, follow-up treatment after an emergency hospitalization).
Get answers to your health insurance questions
If you’re unsure about any of the insurance plan features listed above, the best way to learn about your specific plan is to contact either your employer’s Benefits Office or your health insurance provider. The following list of questions will help you get the detailed answers you need:
First, ask your healthcare provider if it considers CHOP to be in-network or out-of-network.
My child needs services from the Department of _____________ at The Children's Hospital of Philadelphia. (Explain why this is important for your child's care.) I need to understand if my insurance will cover/pay for my child's care at this hospital. Do you consider CHOP and its physician (billing) groups to be “in-network,” a “preferred provider,” a “non-preferred provider,” or "out-of-network?"
- If CHOP is in-network or a preferred provider, please read the section below this box.
- If CHOP is a non-preferred provider or out-of-network, jump to the next section.
If CHOP is in-network, ask your insurance provider the following questions:
- What are my covered services?
- What are my covered benefits? When will my coverage begin?
- What will my cost-sharing responsibility be?
- Please explain my co-payment (co-pay) responsibilities.
- Please explain my co-insurance responsibilities.
- Please explain my deductible responsibilities. How much have I paid towards my deductible so far? How much do I still need to pay?
- Is there a difference in my cost-sharing/financial responsibility amounts based on services received (i.e., Emergency Department, inpatient, outpatient etc.)?
- Can my child have labs or other testing done at CHOP? If he or she has these tests done at CHOP, what will my cost-share/financial responsibility be?
- Questions about my child:
- How do I ensure that my newborn baby will be added to my plan? What date will that coverage begin?
- If my child is born with a complication and/or special needs, can the plan refuse the coverage?
- At what age and under what conditions will my child’s coverage end?
- Is there anything in this plan about pre-existing conditions?
- Referrals and pre-approvals/pre-authorizations:
- Do I need referrals for my child to receive care? For what services? What is the process for getting them?
- Do I need pre-approval/pre-authorizations for my child to receive care? For what services? What is the process for getting them?
- Is there a lifetime maximum on this plan? Have I met it or am I close to meeting it? What do I do when I meet it?
- What tools can I use to estimate my out-of-pocket costs?
- Can I view my Explanation of Benefits online to view what I owe, what I have paid and what insurance has paid?
- For my Employee Benefits Office:
- Do I have the following and how do I access them?
- Flexible spending account (FSA)
- Health savings account (HSA)
- Health reimbursement account (HRA)
If CHOP is out of network, ask your insurance provider the following questions:
- Do I need to obtain a pre-authorization so that my child can be seen by a CHOP physician or have labs or other diagnostic tests done by an out-of-network or non-preferred provider (like CHOP)?
- If so, how do I get that pre-authorization?
- How much of the cost of the visit(s) and test(s) will I have to pay if I go to an out-of-network or non-preferred provider (like CHOP)? How would this be different if I went to an in-network provider?
- What information do I tell CHOP about the pre-authorization when I call to make my appointment?
- Will I need to get this pre-authorization for just the first visit, or will I need it each time if I go back for more visits?
- In addition to the pre-authorization, will I need to bring a referral from my primary care physician for my child's visit to CHOP?
- If you do not provide pre-authorization, can I still bring my child to CHOP?
- My child is seeing providers from more than one billing group (see below) during our visit. Can I check to see if each group is covered, and if I need a separate pre-authorization for each one?
- CHOP billing groups include:
- The Children's Hospital of Philadelphia (CHOP)
- Children's Anesthesiology Associates (CAA)
- Children's Surgical Associates (CSA)
- Radiology Associates of Children’s Hospital (RACH)
- Children’s Healthcare Associates (CHCA)
- CHOP Care Network Practices (MSO)
- Children’s Hospital Home Care (CHHC)
- CHOP Behavioral Health doing business as The Children’s Hospital of Philadelphia Practice Association (in PA)
- CHOP Behavioral Health doing business as CHOP Clinical Associates (in NJ)
Do you still have questions?
Review our frequently asked questions to see if we've posted the answer you're looking for, or call our Financial Counseling Hotline, 1-800-664-7855.
Reach the Pre-Visit Financial Counseling Hotline at
For answers to your Hospital bill questions, please call
For answers to your Physician bill questions, please call
For answers to your Home Care bill questions, please call
Health Insurance Keywords
The amount the insured person pays, usually a percentage, for a portion of the costs associated with the healthcare service after the deductible has been paid. For example, a health plan might pay 80 percent of covered charges, and the insured person is responsible for the remaining 20 percent. The 20 percent amount is then referred to as the co-insurance amount. In this case, if your bill was $100, $80 would be paid by insurance and $20 is your responsibility. The $20 is the co-insurance.
A set amount that is paid at the time of service (for example, an office visit or a physical therapy visit).
Any financial contribution made by the insured person towards the cost of the healthcare service, as defined by their health insurance policy.
A health service included in the premium of a policy paid by or on behalf of the insured patient. Each health plan may define its own list of medically necessary covered services. It is important to check with your health insurance provider to find out if the service is covered.
The annual amount the insured person must pay for healthcare expenses before the insurance company begins to pay for covered medical services. The amount is determined by the specific policy of the insured person. Many plans have individual and family deductible amounts.
A statement from the health plan that lists healthcare services provided, amount billed, payment made and amount owed by the insured person.
A flexible spending account (FSA) is a special type of savings account that can be used to pay for medical expenses. Your employer deducts a certain amount of money each paycheck and puts that money into the FSA. This transfer of funds occurs before taxes are withheld from your paycheck, so you pay less in tax.
Money in an FSA can only be used to pay for medical expenses, including dental and vision expenses. You may use it for co-pays, deductibles and over-the-counter medications. For more information on how to use the funds in your flexible spending account, contact your human resources department or employee benefits plan administrator.
A health reimbursement account (HRA) is an IRS-approved program that allows an employer to set aside funds to reimburse medical expenses paid by participating employees. Using an HRA has tax advantages that offset healthcare costs for the employees and their employers.
A health savings account (HSA) is a type of account that you can put money into to save for health-related expenses on a tax-free basis.
Physicians, hospitals or other healthcare providers who are contracted with an individual’s insurance plan or network.
The amount specified is the total amount your insurance company will pay on your behalf over the course of your lifetime. This amount begins accruing the date your policy begins and continues until your policy ends for any reason. Unlike the annual out-of-pocket maximum, with the maximum lifetime payout, the amounts that your insurer spends paying your claims carry over from year to year.
With PPO plans, a provider that is outside of the preferred provider organization is a non-preferred provider. Non preferred providers do not have an agreement with the PPO, therefore an insurance company will not reimburse a non-preferred provider at the rates that they would pay a preferred provider. The patient will have a greater out-of-pocket expense when seen when seeing a non-preferred provider.
Physicians, hospitals, or other healthcare providers who do not have a contract with an individual’s insurance company. Some plans allow patients to utilize out of network providers, and when this applies, the coinsurance responsibility is typically higher for the patient/family when utilizing out-of-network benefits. Deductible, coinsurance and out-of-pocket expenses may be higher when utilizing out-of-network benefits.
The physician practices that provide care within The Children’s Hospital of Philadelphia (ex. Anesthesia, Surgery, Radiology, Pediatrics etc.).
The process where, before a patient can be admitted to the hospital or receive other types of specialty services, the managed care company must approve of the proposed service in order for it to be covered by the insurance company. For example, the process of seeking approval for an outpatient surgical procedure from the insurance company is a typical example of a service that requires pre-approval by many plans. Not all services will require pre-approval, but if you are in doubt, it's best to contact your insurance company in advance of obtaining any type of non-emergent healthcare service.
A health problem that existed before you applied for health insurance or tried to enroll in a new health plan. Health reform has eliminated this issue for children, but this provision in the law will not help anyone over age 19 until 2014.
A preferred provider is a provider that has an agreement with the preferred provider organization (PPO). The preferred providers will be reimbursed at the negotiated rate with the PPO.
A referral is a type of pre-approval that health plan members, primarily those with HMOs, must obtain from their primary care physician before seeing a specialist.