Many Americans receive their health care in managed care plans. These plans, typically offered by employers and state Medicaid programs, provide services through health maintenance organizations (HMOs) or preferred provider organizations (PPOs). The plans have their own networks of pediatricians and other physicians, and if you or your employer change from one managed care plan to another, you may find that the pediatrician you’ve been using and whom you like is not part of the new network. Once you have a pediatrician whom you like, ask what plans she is in, and see if you can join one of them if there’s a need to switch from one HMO or PPO to another.
Managed care plans attempt to reduce their costs by having doctors control patient access to certain health care services. Your pediatrician may act as a “gatekeeper,” needing to give approval before your child can be seen by a pediatric medical subspecialist or surgical specialist. Without this approval, you’ll have to pay for part or all of these services out of pocket.
To help you maneuver effectively through your managed care plan, here are some points to keep in mind:
To determine what care is provided in your managed care plan, carefully read the materials provided by the plan (often called a certificate of coverage). If you have questions, talk to a plan representative or your employer’s benefits manager. All plans limit some services (e.g., mental health care, home health care), so find out what’s covered and what’s not.
When you’re part of a managed care plan, primary and preventive care visits usually will be covered, including well-child checkups, treatment for illnesses or injuries, and immunizations. In many plans, you’ll have to pay a portion of the primary care services that your family receives, called a copayment, for each doctor’s visit.
Once you’ve chosen a pediatrician, it’s best to stay with her. But if you feel the need to switch, all plans allow you to select another doctor from among those who are part of their network. The plan administrator can give you information on how to make this change; some plans allow you to switch only during certain time periods called “open enrollment.”
If you feel that your child needs to see a pediatric subspecialist, work with your pediatrician to find one who is part of your plan, and obtain approval to schedule an appointment with her. Check your plan contract for details about whether your insurer will pay at least a portion of these costs. Also, if hospital care is needed, use your pediatrician’s guidance in selecting a hospital in your plan that specializes in the care of children. (Most hospital procedures and surgeries require prior approval.)
Know in advance what emergency services are covered since you won’t always have time to contact your pediatrician. Most managed care plans will pay for emergency room care in a true emergency, so in a lifethreatening situation, go immediately to the nearest hospital. In general, follow-up care (e.g., removing stitches) should be done in your pediatrician’s office.
To file a complaint—for example, if coverage of certain procedures is denied— start by expressing your concern to your pediatrician. If she is unable to resolve the problem, contact your plan’s member service representative or employee benefits manager about filing a complaint. If a claim has been denied, you typically have fifteen to thirty days to file an appeal, and you should receive a decision about the appeal within thirty to ninety days of the request. If you still are dissatisfied, you may decide to seek help from the office of your state insurance commissioner, or you can take legal action.