Questions for My Health Plan or Insurance Company

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This fact sheet will help families find out how much services will cost and the paperwork required when looking for medical care, therapy services or other treatment for a child with special needs. 

What Do I have coverage for? 

If your child needs a new medical treatment or service and you are not sure if your insurance will pay for it, call the insurance company or health plan. Before your call, have the following information ready: 

• Your health insurance, HMO member number or plan identification number
• The name of the medical provider and contact information, including the clinic address and phone number
• The number of visits requested, over what period of time (for example, 6 physical therapy visits, over the next 3 months)
• Do I have a deductible? How much is it?

A deductible is the amount you owe for covered health care services before yourinsurance begins to pay. For example, if your deductible is $1,000, your plan won’t payanything until you’ve met your $1,000 deductible (paid $1,000 out of pocket) forcovered services. The deductible may not be applied to all services, including manypreventive health services like immunizations and well-child visits.

Do I have a co-pay or co-insurance?

A co-payment (or co-pay) is an amount you may be required to pay as your share of thecost for a medical service or supply, like a doctor’s visit or prescription. A co-pay is usually a set amount, rather than a percentage. 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 servicesafter you pay any deductibles. Coinsurance is usually a percentage. For example, you will be responsible for paying 20% of the bill for a doctor’s visit.

Is there an out-of-pocket maximum before the plan will pay for my care?

An out-of-pocket maximum or limit is the most you pay during a year (1 policy period) before yourhealth plan starts to pay 100% for covered benefits. This limit must include deductibles, coinsurance, copayments or similar charges. This limit does not have to count premiums, amountsfor non-network providers and other out-of-network cost sharing.

Is the provider in my network? If not, who is in the network that offers asimilar service?

A network is a group of providers that your insurance company or health plan works with mostoften. Staying within the network can help with coordination of your medical care. However, many health plans will cover the cost of seeing a non-network provider if a similar provider or specialist is not available within the network.

Do I need a referral or prior authorization for services?

A referral is an order from your primary care doctor to see a specialist or get certain medical services. Many health plans require you to get a referral before they will cover the cost of care from anyone except your primary care doctor.

A Prior-Authorization (PA) is a decision by your health plan that a treatment or service is medically necessary. A PA is sometimes called an authorization request or prior approval. A provider will fill out the PA paperwork, have it signed by your primary care doctor and submit it to the health plan. You may ask for a copy and can provide additional information, especially if the PA has been denied and needs to be resubmitted. 

Can I have a copy of my Summary of Benefits and Coverage?

A Summary of Benefits and Coverage (SBC) is the explanation of services that are covered under your plan. It details the cost of care, such as co-payments and deductibles. The summary is the contract between you and your plan. It is not the marketing brochure you might get from your employer .