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Important Questions to Ask

When choosing a plan, there are many things to think about. However, there are also a few very important questions you will want to ask when deciding which policy to buy.

Questions to ask of the health insurance plan

  • Is Cook Children's medical center on your plan(s)?
  • What about my Cook Children's pediatrician and/or specialist, are they included in your plan network?
  • If Cook Children's is not in your network, do I have to change my doctors and other health care services?
  • What providers do you offer on your plan(s)?
  • How can I find out if my providers are in your network?
  • Does the plan cover services such as:
    • pediatricians
    • pediatric specialty care
    • pediatric emergency care
    • pediatric urgent care
    • pediatric hospitalization
    • pediatric home health
    • pediatric pharmacy
  • Does the plan charge a premium in addition to the Medicare Part B premium?
  • Are there copayments for doctor visits? If so, what are they?
  • Does the paln pay for prescriptions? How much?
  • Am I allowed to choose my pharmacy or do I need to fill prescriptions at a specific pharmacy?
  • Are the drugs the plan pays for limited to those on a specific list of drugs (called a formulary)?
  • What about the drugs I currently use, are they covered under your plan?
  • Will I be charged more if I use a doctor or hospital outside the plan? How much?
  • Does the plan have maximum amounts it will pay for different services?
  • Are there set limits on what doctors and hospitals can charge?
  • Is there a deductible or coinsurance for inpatient hospital services, home health or skilled nursing facility services?
  • Are routine physicals covered?
  • Are eye exams, glasses and contacts covered?
  • Is there coverage for dental exams/treatments?
  • What about programs that focus on helping members with specific, chronic conditions such as asthma, diabetes or heart conditions, are they covered?
  • Is there coverage for mental health issues?
  • 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?

Ask your medical provider about plans

  • Do you accept this plan?
  • Are you taking patients on the this plan?
  • What hospitals do you refer to?
  • What services does your organization offer?

Questions for your employee benefits administrator

  • What plans do you offer and what are the cost comparisons?
  • How can I be sure the plan I choose offers the health care services I need, including the adults and children in my family?
  • Are there changes in my plan since last year I should be aware of (carve outs, changes in providers and provider networks, copays, deductibles, etc.)?

Questions about billing and insurance

Is my child's care covered under my insurance?

Every plan varies, including what services are covered and which providers are covered for payment under the plan. Prior to making an appointment or scheduling a service or treatment, you will want to check with your insurance plan provider to ensure that your child's care is covered under your particular policy. Prior to your visit, you will want to contact your health insurance plan with questions about your insurance coverage. It's also important to ask if you will need a referral authorization. If your insurance requires authorization and you don't have it, you could be responsible for the entire cost of the bill for your child's care, services and treatments. You will also want to ask about copayments and any deductibles so you understand what kinds of costs you may be required to pay out of your own pocket.

What HIPP parents know

Even with private insurance and Medicaid, the cost of medicine and care for a child with a serious condition can still create a tight budget. For some families, there may be help from HIPP. HIPP is a state program that assists qualified families with private health insurance costs. Click here to learn more.

Will I owe any money for my child's care?

Any dollar amount you are required to pay will depend on the benefits offered under your health insurance plan. Prior to making an appointment or scheduling a service or treatment, you will want to check with your insurance plan provider to determine what your out-of-pocket costs will be, if any. The amount is typically determined by whether or not the care is covered under your policy and what your copay and deductibles are. Copays are due at the time services are provided; any deductibles and out-of-pocket expenses you are responsible for will be due as well.

Who do you bill for my child's medical care?

For scheduled procedures, we bill you for the portion you owe, such as copays an/or deductibles, as well as any portion (out-of-pocket expenses) your insurance may not cover. These fees are due prior to the procedure. We will bill your insurance company directly for their portion. After your insurance processes your claim, you will be responsible for any remaining balance. If you have Medicaid or are on our charity plan, all costs are covered and you will owe nothing. If you don't have any insurance we will bill you directly. Also, depending on your financial situation, we may be able to assist you with receiving Medicaid, in which case your child could be covered for services and treatments we provide. If you need financial assistance, please ask us or visit this page for more information on financial assistance.

How do I know if my insurance has been billed?

Most insurance companies provide online access to your account through their websites. You can also contact your health insurance plan at the number on your member services card. If your insurance is employer-provided and you are unsure about how to contact your health insurance plan, please check with your employer's benefits administrator.

Was my correct insurance billed?

We bill your insurance companies based on the information you provide. We know that during stressful times mistakes can happen. Please check with your health insurance plans if you have questions. Most insurance companies provide online access to your account through their website. You can also contact your health insurance plan at the number on your member services card. If your insurance is employer-provided and you are unsure about how to contact your health insurance plan, please check with your employer's benefits administrator.

How do I make sure my insurance is billed correctly?

Prior to your visit, you will want to contact your health insurance plan with questions about your insurance coverage, copayments or deductibles. Bring the following information to your child's appointment:

  • Your photo identification and insurance card(s).
  • Paperwork for referrals, authorizations and doctor's orders.

What is pending (waiting to be paid) with my insurance?

There are two ways to check on what has been paid, what is pending and what is owed. You can set up a My eBill account here. Our online account management service lets you view your bills, including recent insurance payments and more. You may also check directly with your insurance plan provider. Most insurance companies offer online access to your account through their website. You can also contact your health insurance plan at the number on your member services card. If your insurance is employer-provided and you are unsure about how to contact your health insurance plan, please check with your employer's benefits administrator.

Why is it taking so long for my insurance to pay?

There are a number of reasons why your insurance has not paid yet. If you are concerned, please contact your insurance plan provider directly. Most insurance companies offer online access to your account through their website. You can also contact your health insurance plan at the number on your member services card. If your insurance is employer-provided and you are unsure about how to contact your health insurance plan, please check with your employer's benefits administrator.

Why didn't my insurance pay a bill?

If you have not received an explanation of benefits from your insurance plan provider you will want to call them directly. If you have received notice from them, you will also need to contact them. Most insurance companies offer online access to your account through their websites. You can also contact your health insurance plan at the number on your member services card. If your insurance is employer-provided and you are unsure about how to contact your health insurance plan, please check with your employer's benefits administrator. In addition, you may want to explore how to appeal a payment denial. Please see "Appealing insurance denials."

What can I do if my insurance denies payment of a bill?

If your insurance has denied a payment, you have the right to appeal that denial.

What if I don't have insurance? Where can I start?

What if I can't pay my bill or the part of the bill I'm responsible for?

If you are experiencing financial difficulties we may be able to help. Please check our information on financial assistance:

Help for uninsured or underinsured children

I still have questions, who can I call?

For questions about your coverage, copayments, deductibles and referral and authorization requirements, read your plan's benefits carefully. If you have billing questions, read all bills carefully to find the phone number to call for assistance. Or call your employer's benefits office for explanations. Not all bills will come from Cook Children's. If you have questions about your Cook Children's Medical Center bill, please call 682-885-4432 or if calling from area codes other than 817 or 682, call toll-free at 888-852-6635.