Throughout the year we assist families in navigating the complex world of health insurance, billing, and payments. We often find our patients' families have selected plans with unexpected cost sharing, or experience changes to their provider network where our group is not included. These problems can happen to families with any health insurance, including plans subsidized by an employer.
Before you select health insurance, please review these top 3 questions your should ask when choosing a plan.
For detailed information about any health insurance plan, including network providers, costs, and covered services, the best contact is each plan's Member Services department. That phone number is available from your plan ID card and/or the plan web site.
This information is for educational purposes only and it should be used only as a guide.
| 1. How Much Does It Cost?
It can be tempting to consider selecting an insurance plan based on lower premium costs. Please be aware that lower insurance premiums often mean higher out-of-pocket expenses for services. Lower cost plans may also limit services, or exclude some services altogether.
Additionally, many plans now require a cost-sharing structure that goes beyond a standard copay.
TO DO: Compare all costs of an insurance plan, not just the premium. Additional costs may include:
- Deductible - a minimum amount of money you must pay out of pocket every year before the insurance plan will pay any costs
- Coinsurance - a payment structure that allows for a fixed percentage of costs to be paid by the insurance plan, and a fixed percentage to be paid by you
- Copay - a fixed amount you are required to pay for certain types of care, such as office visits, specialist care, or hospital admission
- Out-of-pocket maximum- the maximum amount you would ever have to pay from your personal financial resources during the plan year
TO DO: Be sure you understand the full scope of shared costs on any plan you are considering. Some plans use a combination of shared costs, for example:
- A plan with a deductible may also have coinsurance. This means a fixed percentage of cost for visits and services are still the patient's responsibility to pay even after the deductible is met.
- A plan with a copay may also have coinsurance. This means even though a fixed amount was paid for an office visit, a percentage of any additional services (such as screenings or lab tests) is still the patient's responsibility to pay in addition to the copay.
| 2. Are Your Trusted Health Care Providers in Network?
Health care providers are contracted with managed care companies to accept certain insurance plans. Examples of managed care companies include United HealthCare, Blue Cross Blue Shield, Humana, Aetna, and many others. Each of these companies can offer hundreds of different insurance plans.
PHCA is contracted with most of the major managed care companies, which are listed on our web site; however these companies don't include all contracted health care providers on every plan they offer. Due to the volume and variety of plans, it's not feasible to publish an all-inclusive list of plans we are included on as in-network providers.
In addition, managed care companies can change the provider network and covered services on their plans each year.
TO DO: Before selecting any new health insurance plan, verify your preferred health care providers are included in network, including your PHCA pediatrician.
Before renewing your health insurance plan each year, review your plan coverage to verify your current providers are still in network.
TO DO: If you have employer-subsidized insurance, consider contacting your HR department now to ensure your current health care providers remain in network if any plan changes are being considered, and that PHCA is included on the plan.
| 3. What If I Am Eligible for a Marketplace or Medicaid Plan?
If you are considering changing insurance to a Marketplace or MMA (Medicaid) plan for any reason, please review the information below.
Marketplace Plans | Affordable Care Act (ACA)
We receive many inquiries regarding the ACA and whether we accept any of the marketplace plans. It is up to the managed care companies if they choose to include us in the network for any plan, and we are not always notified or given specific plan names.
Even if we are contracted with a major managed care company (eg United HealthCare, Humana, etc.) that does not mean we are included in all of their plans, including marketplace plans. Each company can have hundreds of plans, and each of those plans can have different provider networks included.
TO DO: Check the participating providers listed for any plan you are considering. If our pediatricians are not listed, that means the plan has not included PHCA in their network.
If PHCA is not listed on a plan you are considering, be aware that plan may have a narrow network that does not include a variety of providers. In addition the plan may not cover a full range of benefits and services, and may have hidden costs above and beyond the premium.
MMA (Medicaid) Plans
PHCA accepts only Amerigroup and Sunshine Health from the state MMA plans, and our offices are limited on the number of patients we can accept on those plans. Many of our offices have reached the maximum so their patient panels are currently closed to new patients; however see below for exceptions for established patient families on these plans.
At this time only our Northside Office and Crossroads Office can accept new patients on Amerigroup and Sunshine Health.
Important! We do not accept the Amerigroup sub-plan called Florida Healthy Kids.
TO DO: ESTABLISHED PATIENTS
- If your family has an established patient at any office on Amerigroup or Sunshine Health, and you are pregnant or adopting, please contact your pediatrician's office regarding our sibling policy. Every effort will be made to accommodate siblings of established patients so you can stay at the same office.
- Established patients may stay with your current PHCA office if you change your insurance to Amerigroup or Sunshine Health for any reason. Please contact your PHCA pediatrician's office to provide new insurance information.
TO DO: NEW PATIENTS
(This information is for those who may receive our newsletter but have not joined the practice yet, or for established patients who wish to share information with family or friends on MMA plans.)
- Be sure to select either or Amerigroup or Sunshine Health.
At this time only our Northside (USF area) and Crossroads (St. Petersburg) locations can accept new patients on these plans. You may contact either office for your first appointment.
We hope you find this information useful when considering your options for health insurance.
If you have additional concerns about your insurance options and wish to contact your pediatrician's office, we will assist in any way we can.