Commercial Insurance and HMOs
If your family has commercial or private health insurance (e.g., Blue Cross / Blue Shield, with major medical coverage), benefits are comprehensive. Usually, you have to pay the coinsurance amount, which is about 20 percent of each medical bill after a deductible has been met. Plans vary from state to state.
Many families have managed care plans known as Health Maintenance Organizations or HMO's (e.g., CIGNA). Doctors, hospitals, and labs agree to accept fees which are preset. Usually, HMO's require referrals from primary care doctors before appointments are made to see rheumatologists or other specialists. Make sure that our rheumatologists are included in the network, or list, of doctors approved by your HMO. If not, payment will be denied or you may have to pay a significant portion of the cost out of pocket rather than a copayment which will vary according to your insurance plan.
It is important for families without insurance to know that during the open enrollment period, HMO's will accept all people who apply. However, premiums or the amount you pay each month, can be very expensive. For more information about HMO's in Ohio, call or write:
Ohio Department of Insurance
Managed Care Division
2100 Stella Court
Columbus, OH 43266-1526
Toll free 800-686-1526
Some insurance companies offer still another type of managed care plan called a Preferred Provider Organization, or PPO. The advantage of these plans (e.g., Aetna U.S. Health Care) over HMO's is that enrollees have the option of going out of network to see doctors who are not part of their plan by paying higher fees (70 to 80 percent of "reasonable and customary costs"). Check your plan to see if it is a PPO.
A third type of managed care plan, a Point of Service Plan (POS), is similar to an HMO plan in that subscribers are assigned to a primary care doctor from within the POS network. Like a PPO, enrollees can go outside of the network by paying a higher fee.
Pre-Existing Conditions
Persons with arthritis may be classified as a high risk because they have a pre-existing condition – a diagnosed health problem that has required treatment prior to applying for the insurance. When you apply for insurance coverage or change insurance companies, check to see if there is a pre-existing condition clause. Some companies may offer an "exclusion rider" for the pre-existing condition. This means all benefits are paid except for that condition (such as arthritis, lupus, etc.). Other companies may delay the start of coverage for the condition (no more than one year), while everything else would be covered. Still others may put a limit on the amount of benefits they will pay for a pre-existing condition. Make sure you check your plan.
For more information about the William S. Rowe Division of Rheumatology at Cincinnati Children's, please contact 513-636-4676.
