Insurance

Insurance is an important part in your child’s medical care and knowing your child’s coverage will help you be a better advocate for your child.

What are the types of insurance?

Insurance organizations, also called managed care organizations (MCOs) and health maintenance organizations (HMOs) may require you to see a primary care physician first, who will determine whether to refer your child to a pediatric orthopedist. In most cases, the managed care organization will not pay for a visit to a pediatric orthopedist unless you get a referral.

If you see a pediatric orthopedist without a referral, you may have to pay for all or most of the cost of the visit out-of-pocket and find yourself with no insurance for needed tests or procedures. This is why it is important to check with your health insurance provider to see if a referral is required before a visit to an orthopedic specialist.

Preferred provider organizations (PPOs) allow you to see only the doctors who belong to the PPO network. If your pediatric orthopedic surgeon is not on the list of approved providers who are part of the PPO plan, you’ll have to pay an extra fee to see him or her.

These insurance plans are typically offered by employers, but may be purchased by individuals outside of employee benefits.

What should I know about costs?

Understanding these terms will help you determine additional cost to you:

  • Premium payment – cost you pay for your insurance plan.
  • Co-payment – the amount you pay for office visits or hospital services.
  • Deductible – the amount you have to pay out-of-pocket before any insurance coverage is applied to services.
  • Extra costs – these amounts may be applied for emergency care or visits to out-of-plan doctors.

What should I know when choosing a pediatric orthopedist?

Many people prefer to be treated by a doctor they know and trust. That’s important for the patient who has been seeing the same doctor for years, and for the person who hears good things about the doctor from a relative or close friend. Some important questions to ask about your plan include:

  • Will I be able to see my pediatric orthopedist of choice?
  • Can my pediatric orthopedist join the plan I have already?
  • Does my plan have an option to allow me to see any pediatric orthopedist, even if he or she is not in the plan?

What if I’m not happy with the plan I have?

Investigate whether your plan has an appeal process. It may be time consuming, but be active on behalf of your child. If you are not able to get a quick resolution of your concerns with your plan, changing plans maybe an option. Be aware of clauses in insurance plans that address certain medical conditions that are already being treated. These “pre-existing” clauses may cause a lapse in insurance coverage for certain services needed for your child.

What if I do not have health insurance coverage for my child?

Other options for health insurance coverage that may be available for your child include Medicaid and Child Health Insurance Programs (CHIP). These programs are federally funded and state administrated. They are based on the age of your child and income of your family. Some plans are based on the medical needs of your child. Each state has different rules about the eligibility and the services offered by these programs.


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