Guide: Health Insurance

You've heard the saying, "what you don't know can hurt you." When it comes to health care insurance, what you don't know can COST you.

We're here to help you better understand health insurance in general because information is power. And, when it comes to your child's health, it's very important to know what your insurance will and will not cover.

At Cook Children's, we want every child to have access to the best pediatric care possible. Not all insurance policies provide coverage for specialized medical care for children. Here, we provide you with information you need to choose a plan that covers your child's unique needs.

We provide basic information on health insurance, what kinds of policies are available, how to save money on insurance costs, who to contact when you have insurance questions and the kinds of coverage available to children in Texas under the new health laws. We also provide direction on where to turn for help if you run into complications. It is important to understand insurance and we're here to help give each family the tools they need to find the best coverage for their needs, so you can keep your focus on the child that matters most ... yours.

First things first

When negotiating insurance contracts with insurance companies, Cook Children's is always focused on ensuring the best quality of care and coverage on behalf of the children and families we serve.

There are hundreds of health care plans and each one is different. Even employer-provided plans of the same name may be different from company to company, depending on the types of coverage your employer selects. For this reason, you should check with your health insurance plan to ensure that Cook Children's is included in your health plan's provider list. Children are not small adults and having them treated by pediatric doctors and medical experts who understand kids helps to ensure the very best care for your child.

You should also note that insurance plans change provider lists quite often. Anytime your child is referred to a specialist or requires medical treatment, it's helpful to check with your health insurance plan before scheduling an appointment or procedure. Not checking with your health insurance plan could result in large expenses that aren't covered under your insurance plan. This means you will be required to pay out of your pocket for uncovered doctor and medical bills.

Things to know when shopping for insurance

Every year, people change health plans for various reasons, but what you may not realize is that every plan offers a different list of health care providers. In fact, sometimes a plan will change during the year, dropping and/or adding health care providers. These changes might mean that your current doctor, hospital, specialist and other medical treatment and medical service providers may not be covered and this can have an effect on the coverage of care for your child. This isn't related to the current changes in health care; it's related to negotiations between health insurance plans and medical providers. Shopping for insurance or choosing between plans offered by your employer can be confusing and overwhelming, but if you're armed with the right questions, you can make wise choices that are best for you and the needs of your family.

What to ask

To help you through the process, here are some helpful questions to consider as you shop for health insurance:

Does the plan...

Cover services such as:
- pediatricians
- pediatric specialty care
- pediatric emergency care
- pediatric urgent care
- pediatric hospitalization
- pediatric home health
- pediatric pharmacy
Charge a premium in addition to the Medicare Part B premium?
Charge copayments for doctor visits?
Pay for prescriptions? How much?
Allow me to choose my pharmacy or do I need to fill prescriptions at a specific pharmacy?
Limit the drugs it pays for to those on a specific list of drugs (called a formulary)?
Cover the drugs I use?
Charge more if I use a doctor or hospital outside the plan? How much?
Have maximum amounts it will pay for different services?
Set limits on what doctors and hospitals charge you?
Charge a deductible or coinsurance for inpatient hospital services, home health or skilled nursing facility services?
Cover routine physicals?
Cover eye exams, glasses, contacts?
Cover dental exams/treatments?
Cover programs that focus on helping members with specific, chronic conditions such as asthma, diabetes or heart conditions?
Cover mental health issues?

With the plan...

May I use my regular pharmacy?
Can I use Cook Children's pediatric pharmacy?
Are mail-order pharmacies available?
What is the annual or quarterly dollar limit on prescription drug coverage?
Will I have to pay more if I prefer to use brand name instead of generic drugs?
Is there a maximum out-of-pocket cost for prescription drugs? What is it?
Are the hours and location of its doctors, clinics and other health care providers convenient?
Is my access to emergency care and pediatric emergency care convenient?
Are the doctors' offices, labs and other services convenient and do they specialize in pediatric care?
Is there coverage for urgent care?
Is the Cook Children's urgent care center nearest me included on the plan?
How fast can I be seen for urgent (non-emergency) care?
Is there a telephone hotline for medical advice?
Are my child's doctors in the plan?
Is there a selection of the doctors, health professionals and hospitals and other pediatric services that my child might need?
Can I get the pediatrician I want? Is he/she accepting new patients under that plan?
Which pediatric providers and locations are covered under your plan?
What pediatric services does your plan cover (tests, treatments, etc.)?
Are there limits on the number of treatments and the length of time treatments are covered?
What are the deductibles? Copayments?
What are the costs for in-network care?
What are the costs for out-of-network care?
What are the deductibles and copayments for emergency care?
What are the deductibles and costs for inpatient care (hospitalization)?
Is Cook Children's Medical Center considered in-network or out-of-network?

Know your benefits

Knowing what medical care is covered for your child and which medical providers, such as doctors, specialists, hospitals, etc., are covered under your plan can help you in making decisions about your child's needed medical care and where to take your child for care. By performing an annual review, you can also determine if the policy you have offers the level of care you, your child and your family need and whether you may need to look at other policies.

One size does not fit all.

There are many different health insurance plans, and each of them offers a whole lot of different benefits and benefit options. The more you know about the kinds of policies available, the easier it will be to find the one that fits your family's needs.

If you already have health insurance coverage, it's very important to review your plan benefits. Commercial plans change quite often, so your coverage and your list of providers may not always be the same. If you're unsure about your benefits, check with your health insurance plan provider. Most insurance companies offer online access to your account through their Web site. You can also contact your health insurance plan at the number on your member services card.

If your insurance is employer-provided and you're unsure about how to contact your health insurance plan, please check with your employer's benefits administrator. He or she may also be able to go over your benefits with you.

If Cook Children's isn't in your plan

If Cook Children's isn't listed as a provider on your health insurance plan, you may still have covered options which you can discuss with your health insurance plan. If you would like to have your child seen by a Cook Children's pediatrician or specialist or to undergo pediatric care and treatment at a Cook Children's Health Care System facility here are some questions you should ask your health insurance plan administrator:

What if Cook Children's is considered an out-of-network or non-preferred provider, can my child still be seen by a Cook Children's physician or be treated at the medical center?
Is a preauthorization required to be seen at Cook Children's and, if so, how do I get the authorization and when is it required?
Does a preauthorization cover all visits for my child's care or will I need a preauthorization for all visits?
What if my child will need multiple services during a visit that will be billed individually, do I need a preauthorization for each service?
Do I need a referral to Cook Children's in addition to a preauthorization?
What is my financial responsibility for out-of-network services (how much will I have to pay) and what are my in-network options and costs?

If you're expecting a baby

Many people assume that they have lots of time after their baby is born to enroll them on their health insurance plan. This isn't always the case. For the health of your baby and to make sure unexpected charges don't hit your budget, be sure to enroll your baby within the first 30 days after the baby's birth. At Cook Children's, we recommend even sooner. Most babies are born strong and healthy, but it's always better to be prepared.

Is your child eligible for Medicaid/CHIP?

Depending on your family size and income, your child may be eligible for Medicaid and/or CHIP. This means that you may be able to access free or low-cost care for your child through the state of Texas.

The state has existing coverage options that could work for you - particularly if you have children, are pregnant or have a disability.

You can apply today by contacting your state Medicaid office.

You can also apply by filling out an application in the Marketplace online.

Medicaid and the Children's Health Insurance Plan

In many cases, if you qualify for Medicaid your children will qualify for either Medicaid or CHIP. CHIP may also provide coverage for children whose parents make too much money to qualify for Medicaid. Learn more about CHIP and Medicaid from the state of Texas here.

What if you're uninsured and can't afford services?

There are some cases where certain hardships simply seem impossible. Part of the Cook Children's Promise is to improve the health of every child in our community. Sometimes this means lending a helping hand by providing charity care or financial assistance to eligible patients. The key qualifications for charity care and/or financial assistance include children who:

Are classified as financially, medically or catastrophically indigent;
Have applied for Medicaid and complied with applicable Medicaid requirements when Medicaid eligibility is a possibility; and
Have been denied financial assistance (e.g., Medicaid, Children's Health Insurance Program (CHIP), Children with Special Health Care Needs (CSHCN), Supplemental Security Income (SSI) or other government-funded programs) from their service area.

These financial options are available to children who are admitted to Cook Children's Medical Center on an emergency basis and don't have the resources to pay for the services. We may also assist families whose children are in current treatment and require financial assistance with other aspects of a child's care which might include such things as lodging, transportation, etc. This is done on a case-by-case basis and only after all other sources of assistance have been explored and/or exhausted. All charity or financial assistance will be granted, if qualified, without regard to gender, sexual orientation, race, creed, color, ethnicity or national origin. Our primary goal is care for the child.

You can

Appealing insurance denials

If your health insurance plan denies a service or payment you can appeal it. The following information is provided by the Patient Advocate Foundation, a national non-profit organization that serves as an active liaison between the patient and their insurer, employer and/or creditors to resolve insurance, job discrimination and/or debt crisis matters relative to their diagnosis through case managers, doctors and attorneys. Patient Advocate Foundation seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability. For more information on Patient Advocate Foundation, go to patientadvocate.org.

Click here for a guide on navigating the appeals process.

Who to ask

If you have questions, the best place to get answers is through your health insurance plan. If your health insurance is employer-provided, you can also contact your company's benefits administrator.

Still need help?

If your child is at Cook Children's or you would like to have him or her seen at Cook Children's but don't qualify for Medicaid and can't afford any other type of health insurance, we are happy to help. To learn more or for information and assistance getting your child covered right away, click here now.