When Your Child Needs Help in a Hurry — A Parent's Guide to Selecting a Health Plan
Introduction
When your child needs help in a hurry, you may not have time to find your health insurance plan's instructions for obtaining emergency care. Selecting the best health plan and knowing the procedure for obtaining emergency care may save you valuable time and money.
The following questions and answers can help you select a new health plan or review the emergency instructions from your present health plan. They are centered around several issues that many parents have questions about:
- Getting Access to Emergency Care
- Choosing and Seeing a Doctor
- Using Services Outside the Plan's Network
- Seeking Prevention Programs
- Addressing Coverage Issues
1. Getting Access to Emergency Care
| Q. |
When you think your child needs help right away, does the plan tell you to call them for permission before dialing 911 or your local emergency medical services (EMS) number? For example, if your child has a seizure after a head injury, can you call an ambulance right away and be sure your insurance will cover it? |
| A. |
Health plans should allow parents to call 911 or the local EMS number when they believe their child is suffering from a life-threatening condition or a condition that may become more serious or lead to a permanent impairment. Check your member's handbook or talk to your health plan's representative to make sure they will cover you for 911 services when you truly believe it is an emergency. |
| Q. |
Does your health plan provide you with access to a doctor or nurse, by telephone or in person, when you are not sure if your child needs help right away? Is this access available 24 hours a day, seven days a week? For example, your child has a very high fever and vomits repeatedly. |
| A. |
Many plans now have nurses and doctors available at a central number at all times to give you advice on the care of your sick or injured child. Other plans instruct you to contact your primary care physician's office. The doctors and nurses may recommend that you come in right away so they can examine your child, or they may schedule a doctor's visit later if the child does not seem to need immediate care. |
| Q. |
Does the plan or affiliated primary care physician provide you with specific information about symptoms that may require immediate treatment? For example, if your child has asthma, does your plan offer you instructions on how to decide when wheezing becomes severe enough that you should bring your child into the doctor's office or emergency department? |
| A. |
Health plans should provide a definition of an emergency that will help you to know when to seek care. Health plans and primary care physicians may also offer classes or training on how parents of a child with medical conditions like asthma or diabetes can help treat their child's illness and prevent serious complications. |
| Q. |
When your child needs help in a hurry, are the plan's emergency departments and physicians the ones you and your family want to use? Do they also have the equipment and experience to care for children's needs? For example, if your child needs treatment for a broken bone, are you satisfied going to the hospital emergency department that your plan wants you to use, and do they have special training and education in caring for children? |
| A. |
Talk with your child's current doctor about which hospital emergency departments near your home and your child's school or daycare are best. Remember that sometimes the hospital nearest to you may not be the most appropriate one for your child's problem. Review your member's handbook or call your health plan's member representative if you are already in a health plan and have concerns about your options. |
2. Choosing and Seeing a Doctor
| Q. |
When your child needs help in a hurry, does the plan give you access to doctors who have experience with children and know how to care for your child? For example, if your child was badly injured in a bicycle fall, would the emergency, surgical, orthopedic, and anesthesia doctors all have the necessary skills to provide your child the best possible care? |
| A. |
Health plans that are prepared to handle all types of medical emergencies will have a large network of doctors available, including specialists from all fields, who can immediately be called to diagnose and treat your child. Your specialist may be a pediatrician, ophthalmologist, or pediatric orthopedist, to name a few. Your plan should allow you to immediately see specialists in an emergency. Care should not be delayed to notify or get permission from your primary physician. Ask to see a list of specialists that may be available to treat your child in an emergency. |
| Q. |
Are the plan's doctors known for providing quality medical care in both a friendly and professional manner? Are you permitted to see results of patient satisfaction surveys that the State or plan conducts? For example, if you want to make sure your child sees a qualified allergist, will the plan let you see the doctor's credentials and patient satisfaction survey results that show whether other health plan members are satisfied with the care they and their children receive? |
| A. |
Many plans conduct surveys to learn whether members are satisfied with the medical care they receive. Some plans also have their doctors and nurses follow guidelines for care, called clinical guidelines, to make sure that the medical care they provide at your health clinic or office is the same as the care they provide at their other sites. In some cases, plans submit themselves to be evaluated by a national independent certification organization, such as the National Committee for Quality Assurance or the Joint Commission on Accreditation of Healthcare Organizations. These organizations measure the quality of care your plan provides by looking at many factors, including patient satisfaction. You should discuss the plan's evaluation with a member representative, if such an evaluation is available. |
3. Using Services Outside the Plan's Network
| Q. |
If your child has a medical emergency while away from home or at college, how can he or she get medical help? For example, your son is at college and needs stitches when he falls and cuts his leg. The stitches must be removed a week later at a local clinic. |
| A. |
Your plan should explain what kinds of conditions are considered emergencies and what they will pay for while your child is away from home or at college. Ask whether the plan provides coverage for follow-up care. Your child's physician or the plan's on-call physician or nurse should be able to provide information to the emergency department about your child's medical history, immunization status, and known allergies by telephone or fax. |
| Q. |
Will the plan cover the cost of emergency transportation to a hospital should your child have a medical emergency while out of the plan's network? For example, your daughter develops a serious infection while visiting her grandmother. The grandmother calls an ambulance because your daughter is getting worse. |
| A. |
The plan should cover the cost of emergency transportation if your child becomes seriously ill while out of the plan's physician network. The plan and your doctor should make it easy for you to contact them for emergency advice and assistance while you are away from home. Some plans provide a toll-free number on your member's health plan card, which you may carry in your wallet, to make this more convenient. The plan should cover the cost of a medically appropriate transfer if you want your child moved to a hometown hospital. |
| Q. |
Will the plan only require a transfer to a network medical facility when your child is considered stable? |
| A. |
The plan should not require the child to be transferred to another medical facility if she is not stable. |
4. Seeking Prevention Programs
| Q. |
Does the plan promote injury prevention and healthy behavior for both parents and children? |
| A. |
Ask if the plan has programs designed to prevent injuries and promote healthy behaviors. Examples of injury prevention programs include workshops that encourage the use of child safety seats, seat belts, and bicycle helmets for children. Other important child safety programs may address poison prevention, child safety tips for parents and babysitters, instructions on how to handle medical emergencies, and information for parents and children on the importance of avoiding drugs and alcohol. Some plans offer counseling programs for parents, pre-teens and teenagers on domestic violence or if alcohol or drug abuse is suspected. |
| Q. |
Does the plan offer safety classes or specific instructions after your child has had an injury so that they can avoid a similar incident in the future? |
| A. |
After an injury, the plan or primary care physician should offer information to parents and children on ways to avoid having a similar incident in the future. Some plans offer bike helmets and child safety seats at a discount. |
5. Addressing Coverage Issues
| Q. |
Do you have to pay part or all of the bill for emergency medical care of your child? |
| A. |
Most plans provide coverage for emergency medical conditions. Some will require you to pay an extra sum--a co-payment, when your child is seen in an emergency department. This co-payment is usually waived if your child is admitted to the hospital. Many publicly funded programs do not include co-payments for emergency services.
Note: Before joining any plan, you should understand the plan's policy regarding payment for care received in an emergency department. Many plans require you to notify them within 24 to 72 hours after an emergency department visit. Failure to do so may mean that you have to pay for the medical care. Some plans require you to call the plan representative to get permission to go to the emergency department for care of certain conditions. Some plans will provide telephone "medical advice" nurses or doctors who may advise you to go to a clinic or wait to see your personal physician rather than go to an emergency department. Your plan should cover emergency care if you believe your child's symptoms make it necessary.
You always have the right to go to the emergency department to have an examination and receive treatment. An emergency department will never refuse to evaluate your child's condition. However, a plan may not pay for a visit if you do not first call, or if the plan determines the condition was not an emergency. At this point you would be responsible to pay for medical care received. In most instances, the plan must have an appeals process available so that you can dispute any refusal to pay for emergency care. Enrollees of publicly funded programs also have access to State hearings and appeals systems and should refer to the member handbook for filing instructions.
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| Q. |
Do you as a member of the plan have any input concerning what a plan will cover when the rules are confusing or when there is a disagreement about coverage? |
| A. |
Many plans encourage input from members like you, and have created ways to receive and evaluate suggestions you may have. As a consumer, you should be allowed to address issues such as the appropriate amount of time to wait for advice from a doctor or nurse about a condition before going to an emergency department for evaluation. Ask a representative from the plan whether you can appeal a coverage decision if you feel you are being asked to pay for a service you believe should be covered. |
6. Be Prepared — The First Step!
Childhood emergencies are very common, and almost every parent is called upon to deal with them. Assuring that your child will receive medical care in an emergency is an important responsibility for a parent. Use these steps as a guide:
Plan ahead. Talk with your physician and health plan abo' the doctors and hospitals your plan covers in an emergency. Ask about procedures you should follow when your child is out of town and has an emergency or needs help from a non-plan hospital emergency room.
Seek Information. Many health plans have emergency treatment protocols and educational materials for parents to help them reduce a child's suffering after a medical crisis. Ask for information about injury prevention programs before emergencies occur. Contact the member services department of various health plans and ask about about additional information to help you prepare to manage a childhood emergency. Your physician may also have materials in his or her office that you can obtain during a routine visit. Your enrollment information and member's handbook can also have valuable information.
Taking these simple steps takes a little time, but a little planning goes a long way to make sure you have the health care services and coverage when your child needs it most.
Special thanks to the EMSC Managed Care Working Group and the EMSC National Managed Care Task Force for their assistance in developing this brochure.
EMSC Managed Care Working Group Members:
Richard V. Aghababian, MD, Working Group Chairperson, Chairman, Department of Emergency Medicine, University of Massachusetts Medical Center
Jean Athey, Ph.D., Director, EMSC Program, Health Resources and Services Administration, Maternal and Child Health Bureau
Jean Moody-Williams, RN, Health Care Finance c Specialist, EMSC National Resource Center
Patricia O'Malley, MD, Director of Pediatric Emergency Medicine, Massachusetts General Hospital
Patricia Salber, MD, Emergency Physician, Physician Director National Accounts, Kaiser Permanente Medical Care Program
Roslyne D. W. Schulman, Regulatory Representative, American College of Emergency Physicians
Robert W. Shafermeyer, MD, Associate Chair, Department of Emergency Medicine, Carolinas Medical Center
Victoria Wicks, President, Chief Executive Officer, HIP Health Plan of New Jersey
Joanne Wilkinson, MD, Physician Coordinator Emergency Services, Harvard Pilgrim Health Care
This publication has been produced by the EMSC. National Resource Center, under its cooperative agreement with the Maternal and Child Health Bureau (MCU-114002)from the Emergency Medical Servicefor Children Program (section 1910 of the U.S. Public Health Service Act), Health Resources and Services Administration, Department of Health and Human Services.