If your child needs to see a new medical provider, start new medications, treatment or therapy service, and you are relying on your family’s private health insurance for payment, it is important to prepare for the potential cost.  These tips and ideas will help you be ready, so you are not surprised by large bills, or unforeseen out-of-pocket costs.  

Where to Start

1. Read your health plan’s Summary of Benefits and Coverage (SBC). This is the document explaining the covered services under your plan. It details the cost of care, including possible out-of- pocket costs like co-payments, co-insurance and deductibles. This document is not the marketing brochure you might get from your employer. It is the contract between you and your insurance company.

2. Check your insurer’s website for information. Many insurance companies offer a member portal where you can find details about your coverage, find in-network providers, and some sites will let you search for specific medical procedures or medications to see if they’re covered.

3. Call Member Services to ask if a treatment or service will be covered. Their phone number will be on the back of your insurance card.

Before calling or getting online, have the following information ready:

• • • Your child’s and/or family’s member number or plan identification number
    • The name of the medical provider and their contact information, including the clinic address and phone number
    •  The number of visits requested, the name of the medication, or other specific details about the medical services recommended

4. Check the Formulary: A formulary is a list of prescription drugs covered by your insurance plan. Insurance companies categorize these into tiers based on cost. Your co-pay will vary depending on which tier a medication falls into. If your child’s medical provider is recommending a new medication that does not appear on the formulary, contact the clinic to see if a similar medication, or a generic version, that is on the list can be substituted.

What to Know about Deductibles

A deductible is the amount you owe for covered health care services before your insurance begins to pay. For example, if your deductible is $1,000, your plan won’t usually cover any costs until you’ve met your $1,000 deductible, or paid $1,000 out of your own pocket, for covered services. The deductible may not be applied to all services, including preventive health services like immunizations and well-child visits.

Know the Difference Between Co-Pay and Co-Insurance

A co-payment (or co-pay) is an amount you may be required to pay as a share of the cost for a medical service or supply, like a doctor’s visit or prescription. A co-pay is often a set amount. For example, you might pay $20 each time you visit your doctor or pick up a prescription.

Co-insurance is the amount you may be required to pay as your share of the cost for services after you pay any deductibles and is usually a percent of the overall cost. For example, you may be responsible for paying 20% of the bill for a doctor’s appointment.