Four Seasons Pediatrics

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Sick Visits, Pandemic impact on Cost-Share

As you know, May marked the end of the Federal COVID-19 Public Health Emergency.   How has this impacted insurance coverage for children?

It is always important that your understand your own insurance coverage, as each coverage can vary. 

Government Programs:

For those on government programs, there were protections in place to ensure that children had continuous coverage even if there were issues with document verification, address changes, undeliverable mail address or not keeping up with premiums for some programs such as Child Health Plus.  For those whose enrollment is due on 6/20/23 or each month thereafter, you will need to ensure that you do the annual renewal on a timely basis, or your children will be removed from coverage.  Please ensure that you are aware of your dates so your child(ren) do not lose coverage.

Commercial Insurance:

For those with commercial insurance, there is no longer a “No cost-share” coverage.  During the National Public Health Emergency – if you had a covid test performed, you did not have a copay, co-insurance or fees applied to your high deductible.  How will this affect those families?

Commercial Plans with a Copay:

If you have a copay, you will now incur a copay for sick visits, or well visits where you have had a significant problem addressed and or testing performed.  Most plans have a fixed copay, but there are some new changes:

• CDPHP – There are many (but not all) CDPHP plans with zero copay and $0 cost-share for primary care physician visits for children ages 18 and under.  This does not apply to those with high deductible plans. 

• Empire Plan of NYS Employees – as of July 1, 2023 – multiple copays are eliminated for PCP visits and the copay is $25.  For Urgent Visits outside our office, there can be up to two copays of $30 (or $60) for each Urgent Visit as of July 1.

• All other plans – please understand your copay or check with your insurance company to be clear about your copay

Commercial Plans with a Deductible:

Many people choose these plans with the significant benefit of lowering your premium.  If you choose one of these plans, it is important to consider a savings account that will pay for visits until you reach your deductible.  (e.g. if you have a $5000 deductible, expenses for medical care will be your responsibility until the first $5000 in expenses is paid by you.)  Unlike a copay (e.g. $20 per visit), you are now likely to be subject to the entire sick visit towards your deductible.  This means that you would be responsible for the visit fee, and any testing that would be done as part of the visit.  In the past, the COVID test insulated you from the fees of any other tests.  With a high deductible, not only are you responsible for the visit fee and the COVID test now, but also any other tests.  While the PCR tests are very accurate, they are also very expensive.  

For all plans (including copay plans and government programs), we highly recommend that you do two home covid tests 48 hours apart.  This will reassure us that you have a much lower risk of a covid illness and will help all of us avoid doing the more expensive PCR COVID test.   We continue to wait for recommendations for testing to change based on current risk.  With the current CDC recommendations, we continue to recommend testing in our office if you have not performed two home tests 48 hours apart.  This is to protect any high risk patients (newborns, immune deficient patients, those with cancer) and high risk staff and their high risk families. 

Sick Visits:   

We continue to struggle with meeting the demands of sick visits.  At times we may request that you treat an illness at home, or that we safely see you within 2-3 days when appropriate.   We hope you can understand that this allows us to see another patient who really needs attention today.  The pandemic has created a culture of see right away, test immediately.  We hope that we can continue to migrate to a strategy where we can say “I think you can treat this at home and we want to go over symptoms that mean you need to be seen”.  Such a strategy opens up more availability for appointments for patients that need to be seen, will reduce the need to travel to the office, reduce the need to take time from your schedule and save you the cost of your copay and deductible.  Even if you have a $0 copay CDPHP plan, with no financial impact from the visit, this will still apply to free up appointments that you want to have available when you need one. 

Well Visits:

If you have a well visit and someone is sick, we ask that you do two home covid tests 48 hours apart.  We will review the symptoms and determine if we feel a PCR test is needed on the day of your visit.  Please note – depending on your insurance (except government programs and $0 copay plans) you are likely to have a cost share for such testing – this is where it is important to know if you have a deductible plan.  The alternative is to reschedule your well visit. 

We hope this information is helpful to you.  As always we want to keep you informed of changes that are significant and impactful to you.

Thank you

Four Seasons Pediatrics

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