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Insurances

Please verify with your policy that we are in-network and please select one of our providers as your child’s Primary Care Physician (PCP).  Please call our office with any questions regarding a specific insurance plan.

Our practice accepts most commercial insurances and participates in many managed-care plans within those insurances (which may require co-payments at the time of a visit) some of which include:

Aetna
Blue Cross Blue Shield
Children’s Medical Security Plan
Cigna Healthcare
Commonwealth Indemnity Plan
Fallon – Commercial plans only
Harvard Pilgrim
Humana
Mass Health – Partners Healthcare Choice ACO
Neighborhood Health – Commercial plans and some Connector plans
Tufts Health Plan – Commercial plans and some Connector plans
United Healthcare

Insurances change frequently, and we want to remind parents of a few details to try to help you through the process:

  • Please bring your child’s insurance card and co-payment to our office each time you visit.
  • Please check your child’s insurance I.D. card to confirm that one of our pediatricians is listed as your child’s Primary Care Physician (PCP) — if your insurance requires that you have a PCP. If any other doctor is listed on the card, please call Member Services at your insurance carrier immediately (telephone number is listed on your card) to change your child’s PCP to a physician in our office so that your insurance will pay for your child’s care in our office.
  • Please inform us immediately if you have a new insurance I.D. number or insurance carrier.
  • Please inform us of any changes to your home address and cell or home telephone number. We would also like to have your email address to keep you informed about the practice so please update your email address with our front desk administrative team as well.
  • When you deliver a new baby, please call your insurance company as soon as possible and ask them to add your new baby to your policy, effective as of the date of birth and give them the name of one of the doctors at MVPediatrics to be your baby’s PCP.
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Common terms in the Health Insurance Industry:

Some additional helpful hints when working with your insurance company:

  • If you must communicate with your insurance company, always remember to ask for a confirmation number when you finish your conversation.
  • For newborns, you have thirty days to enroll your child under your health insurance policy. Please make sure your carrier knows the name of the physician at Mark Vonnegut Pediatrics who is your Primary Care Provider.
  • We encourage our patients to be informed consumers when it comes to your health insurance. When you receive your statement from your carrier and you question it, call them.
  • If you do not receive statements, register for an on-line account so you can personally monitor what your premiums are paying for.

Shopping for Health Insurance?

Let us explain the different policy types, along with other terms that are important to understand.There are generally five different types of insurance policies available; HMO, PPO, POS, EPO, and Fee-for-Service (Indemnity). No one plan is easily distinguished as better than the other, the conditions of each policy will appeal differently to your family’s needs and preferences. Some people enjoy the freedom of being able to see any provider they choose with Fee-for-Service (Indemnity) plans, while others prefer the low costs associated with network oriented HMO policies.

Common terms in the Health Insurance Industry:

Premium – The total fixed amount paid for health insurance on a monthly or quarterly basis.

Copay – A fixed dollar amount you pay at the time services are rendered. Typical copays are for office visits, prescriptions, or hospitalizations.

Coinsurance – A specified percentage of the cost of treatment the patient is required to pay for all covered medical expenses remaining after the deductible has been met.

Deductible – The portion of your health care that you pay before insurance starts covering it. Generally speaking, the higher the deductible, the lower the premium.

Health Savings Accounts (HSAs) – HAS’s were designed for high deductible plans; to pay for routine medical expenses, and or provide savings for the future. Money put into the account can be used either during the year, or accumulated in the account. Allowable medical expenses are defined by the IRS, and are much broader than most insurance carriers (i.e. includes dental, vision). Individuals can deduct dollars contributed to the HSA account from their gross income, resulting in tax-free medical dollars. The account is similar to an IRA account; however, it is for qualified medical expenses.

Preferred Provider Organization (PPO Plans) PPO plans give patients great flexibility in regards to seeing providers. Patients are not required to choose a PCP, and have the ability to “self-refer” meaning that they can make appointments, and see specialist without having to notify their PCP, or wait for a referral. The down side is that with this great flexibility comes great cost; PPO plans typically have higher premium and copay amounts, and often include a deductible amount that must be met before reimbursement begins. Although it is fairly large, PPO plans also expect patients to see in-network providers. The difference in the cost of seeing an in-network providers rather than an out-of-network provider is significant; if a patient were to see an in-network provider, the insurance may reimburse up to 90%, whereas if they were to see an out-of-network provider, the insurance may only reimburse 20-30%.

Health Maintenance Organizations (HMO Plans) HMO plans work on an in-network basis. Patients are required to see providers who are contracted with the health insurance provider and are considered in-network. Plan participants are required to choose a PCP (Primary Care Provider) from a list of in-network providers. The selected PCP will coordinate the health care needs of the patient by submitting referrals/prior authorizations when their patients need to see a specialist. Think of HMO plans as paying in advance for your health care, rather than paying for each service separately. In return for monthly premiums, HMO plans include benefits for additional services such as dental and vision. HMO’s often require copays for services such as office visits, hospital stays, and prescriptions. On the other hand, one of the greater advantages of an HMO policy is that preventative care is often covered in full by the insurance carrier with no patient responsibility.

Point of Service (POS Plans) POS plans are a combination of both HMO and PPO plans. Patients are encouraged to choose a PCP and see specialists that are in-network; however, they do have the option of seeing out-of-network providers at a higher rate. A POS plan will reimburse you for services provided by out-of-network providers, but it will not be for the full service, so there will be a higher patient responsibility than with in-network providers. In order to receive full reimbursement for in-network providers, the patient would need a referral sent by their PCP.

Exclusive Provider Option (EPO Plans) EPO plans are a step down from PPO plans. Patients are not required to select a PCP, but must only see providers who are within the plans contract network. There is a smaller range of contracted providers within an EPO plan. Although the patient has the freedom to see a specialist without needing a referral, the amount of providers they have to choose from is limited. EPO plans typically do not reimburse patients who choose to see out-of-network providers, with some exceptions in emergency situations.

Fee-for-Service (Indemnity Plans) Indemnity plans do not restrict patients to a network of providers. They have set contracted amounts for services rendered, and may not cover preventative care visits. For this reason Indemnity plans are not good for large families, or patients only needing preventative care coverage. Indemnity plans also tend to have the highest out-of-pocket maximums. This means higher copays, coinsurance, and deductibles. In short, Indemnity plans are best for patients who do not want any restriction of having to see an in-network provider.

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