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 you 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 the Member Services department. That phone number is available from your plan ID card and/or the plan website. 

This information is for educational purposes and it should only 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 for 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 the costs 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 that 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 healthcare providers in-network?

Long receding line or queue of smiling doctors and nurses in white uniforms wearing stethoscopes around their necks isolated on white     Note  Shallow depth of fieldHealthcare 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 website; however, these companies don't include all contracted healthcare 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 where we are included as in-network providers.

In addition, managed care companies can change their provider networks 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.

  • Contact the plan's Member Services department. or review the printed or online participating providers list.

  TO DO: Before renewing your health insurance plan each year, review your plan coverage to verify your current providers are still in-network. 

  • Plan changes may not be visible to you as a member.
  • Even if the plan name is the same, the provider network and covered services can change from year to year.

   TO DO: If you have employer-subsidized insurance, consider contacting your HR department as early as possible before open enrollment.

  • If any plan changes are being considered, ensure that all of your current healthcare providers remain in-network, including Pediatric Health Care Alliance. 

 


   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 list of participating providers for any plan you are considering. If our pediatricians are not listed, the plan has not included PHCA in their network.

  • If PHCA is not listed on a plan you are considering, be aware that the 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 Simply Healthcare and Sunshine Health from the state MMA plans, and our offices are sometimes limited on the number of patients we can accept on those plans.

October 2022: At this time the following offices are closed to new patients with these plans: Apollo Beach, Big Bend, South Tampa, Wesley Chapel

 
  TO DO: ESTABLISHED PATIENTS

  • Established patients may stay with your current PHCA office if you change your insurance to Simply Healthcare or Sunshine Health. Please contact your PHCA pediatrician's office to provide new insurance information.
  • If your family has an established patient at any office on Simply Healthcare 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.

  TO DO: NEW PATIENTS WHO WANT TO JOIN PHCA

  • Be sure to select either Simply Healthcare or Sunshine Health as your MMA plan.
  • Be sure to select a PCP (primary care provider) at PHCA. We cannot see patients on these plans if you haven't selected a PHCA provider as your PCP.

 

We hope you find this information useful when considering your options for health insurance.

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