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Insurance and Managed Care


Choosing the Right Health Plan

With so many different health care options available, the best way to find out which plan will best suit your family’s needs is to ask questions. Before you decide, take some time to talk to your doctor, your employer, your healthcare plan representative, your managed care plan representative and your family and friends to make certain that the managed care plan you choose will be the best choice for your family.  We’ve included several questions to consider when choosing your insurance plan.

Questions to Ask Your Doctor

  • Do you currently participate in any of these healthcare plans that I'm considering for my child?
  • If so, how long have you been associated with these plans?
  • Are you planning to stop participating in any of them?
  • What do you think about the services and benefits offered by each plan?
  • Do you know if the physicians to whom you refer patients participate in these healthcare plans?
  • If my child needs to go to the hospital, are you allowed to send him to a children's hospital, specifically to Children's Medical Center?
  • If you need to refer my child to a specialist, do you have to get an approval from the plan?
  • If yes, how easy is it to get approval and how long does it take?

Questions to Ask Your Employer

  • What is the date that my coverage begins?
  • Is there anything in the plan about pre-existing conditions?
  • Are there restrictions on which doctors and hospitals I may use?
  • If so, which providers are under contract with the plan?
  • If the healthcare plan covers a service, but I have to get the service from a provider who is not on the plan's approved list, will the bill be paid at a lower rate?
  • Can the health plan refuse to pay the bill?
  • At what age and under what conditions will my coverage for my child end?
  • If my child is born with a birth defect or other complication, can the health plan refuse to cover my child?

Questions to Ask Your Healthcare Plan Representative

  • Is my child's doctor on your approved list?
  • If not, will I be required to change doctors?
  • If I have to change doctors, can the doctor I choose for primary care be a pediatrician?
  • Is there some way my child's doctor can be put on your approved list?
  • If my child needs to see a specialist, where can we be referred to for care?
  • Are they any conditions that have to be met if my child needs to see a specialist?
  • Does my child's doctor have the final say in referring my child to a specialist?
  • If my doctor and I disagree with the health plan's decision, how do we appeal the decision?
  • If a pediatric specialist has been treating my child for a condition such as asthma or diabetes, will your plan let us stay with this specialist?
  • If my child needs special services at a children's hospital, what is the coverage for these services?
  • Who decides which services will be covered and how is this decision made?
  • Does the plan cover standard services for my child at a hospital specializing in children’s care, such as hernia repair, tonsillectomy or allergy treatment?
  • Is there anything I have to do to get approval from the plan before my child can get services or treatment covered by the plan?
  • What are your rules regarding emergency, after-hours and out-of-town care?

Questions to Ask Your Managed Care Plan Representative

  • What pediatric specialists are employed by or under contract with the plan?
  • Does the plan contract with a children's hospital?
  • Does the plan evaluate how well it serves children, including children with disabilities?
  • If so, how is the evaluation done and who does it? Are the standards used for evaluation specific to children?
  • How does the plan keep track of and resolve enrollee complaints?
  • Is there a consumer board or committee that reviews complaints?
  • If a complaint can't be resolved informally, what is the formal appeals process?
  •  If my child has a condition such as asthma or diabetes, will all of the treatments my child is now getting be covered by the plan?
  • Will the plan allow me to continue using the healthcare providers I am now using to treat my child?
  • Is the plan certified or approved by an outside agency, such as the National Committee for Quality Assurance (NCQA)? A plan that is certified by NCQA must meet certain standards on doctor qualifications. It also must have programs in place that address enrollee complaints and ensure standards of care.
  • Is the plan federally qualified? A plan that is federally qualified offers comprehensive benefits, has programs to address complaints and ensure standards of care, has a ceiling on out-of-pocket costs and protects enrollees if the plan goes out of business.

Questions to Ask Your Family and Friends

  • Which healthcare plan do you have and how long have you had it?
  • How did you choose your health plan?
  • Are you satisfied with your healthcare plan? If yes, what do you like best about the plan? If no, what don't you like about the plan?
  • Were there any times you or your doctor could not get the services you wanted or needed for your child?
  • Have you been able to get special care and second opinions when your child needed them?
  • Have you had any problems getting your questions answered or having your claims or bills taken care of in a timely way?