How Primary Care is Covered
Managed care plans usually pay for primary and preventive care visits, including:
Many managed care plans require families to pay a share of their primary care services, such as $5 to $20 for each visit to the doctor. Copayment and coinsurance rules are set by the insurance company, and the pediatrician must follow those rules in terms of billing and collecting any amounts due as determined by the insurance company.
High Deductible Plans
Under high deductible plans, you may be responsible for payment until the deductible has been met, unless your plan was purchased after March 10, 2010. All high deductible plans purchased after March 10, 2010 must include 100% coverage for preventive services even if the deductible has not been met.
Know the extent that your plan covers preventive and primary care and remember to bring your insurance card with you to each visit. Ideally, the health plan should provide coverage for all recommended pediatric preventive care. See the current AAP Recommendations for Pediatric Preventive Care Services for more information.
How to Choose a Primary Care Doctor for Your Child
It is recommended that you choose a pediatrician as your child's primary care doctor. A pediatrician has years of training and experience in children's health care.
If your pediatrician is not in the plan, you can ask the plan to include him or her. If you go to a pediatrician who is not in the plan, your plan may not fully pay or even partially pay for your care.
Ask your pediatrician which plans he or she is in and try to join one of those plans.
Before choosing a plan, you also should think about the hospitals your pediatrician is able to admit patients to and the pediatric specialists he refers patients to.
If you do not have a pediatrician, you may search the "Find a Pediatrician" tool on HealthyChildren.org or you can ask your managed care plan for a current list of pediatricians near you whose practices are open to new patients.
The Pediatrician's Role in Managed Care
A pediatrician provides primary care for newborns, infants, children, adolescents and young adults. As a primary care doctor, he provides preventive care, takes care of illnesses and injuries, and diagnoses and treats acute and chronic disorders.
A pediatrician makes referrals to pediatric specialists when needed and coordinates other services for the total care of your child. Your plan may require that your pediatrician serve as a "gatekeeper" to authorize or approve certain services. Without these approvals, you may have to pay for part or all of these services yourself.
If You Want to Change Doctors...
Finding a pediatrician who meets your family's needs is important. It is also best to stay with that pediatrician once you have made your choice. However, situations change and you may need to choose a new pediatrician.
All plans allow you to choose another doctor from those participating in the plan. Check with your plan to get information on how to do this. You must let your plan know if you change your pediatrician. Some plans only allow you to change doctors during a specific period of time.