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?
- Tools:
- 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)
- Do I have the following and how do I access them?
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.
Contact Us
Reach the Pre-Visit Financial Counseling Hotline at
1-800-664-7855
For answers to your Hospital bill questions, please call
1-800-283-3055
For answers to your Physician bill questions, please call
1-877-724-2467
For answers to your Home Care bill questions, please call
1-800-866-1242