Please click on any of the following types of insurance to find out more information about Stanford Medicine Children’s Health’s status with these plans.
Coverage for your care at Stanford Medicine Children’s Health is determined by your insurance company and is based on the provisions of your specific plan.
We strongly recommend contacting your insurance company directly prior to your visit at Stanford Medicine Children’s Health to verify the following:
Tip: Whenever you speak with your health plan, it is beneficial to write down the name of the health plan representative you spoke with and reference number (if applicable) for future reference.
Should you have any other coverage/benefit questions after speaking with your insurance about an upcoming appointment, please contact our Financial Counselors at (650) 736-2273, 8 a.m. – 4:30 p.m.
For more glossary terms, please visit to http://www.healthcare.gov/glossary
Preferred Provider Organization: A type of health insurance plan that contracts with medical providers such as hospitals and physicians to create a network of participating providers. There is a financial incentive to use in-network providers by offering higher benefit coverage than out of network providers. Health care services received from providers that are “in-network” are covered at an in-network benefit level, while out of network providers are covered by out of network benefits, which are typically more expensive. Patients can typically self-refer to specialists, but are responsible themselves for making sure that all providers are in-network.
Exclusive Provider Organization: A type of health insurance plan in which choosing a primary care provider is not required but providers seen must be within the predetermined network. Out of network care is not covered except in an emergency. Patients can typically self-refer to specialists, but are responsible themselves for making sure that all providers are in-network.
Health Maintenance Organization: A type of health insurance plan in which choosing a primary care provider is not required but providers seen must be within the predetermined network. Out of network care is not covered except in an emergency. Patients can typically self-refer to specialists, but are responsible themselves for making sure that all providers are in-network.
Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
Co-insurance: The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
Out of Pocket Maximum: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit doesn't include your monthly premiums. It also doesn't include anything you may spend for services your plan doesn't cover.
Referral: A written order from your Primary Care Physician for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your Primary Care Physician. If you don’t get a referral first, the plan may not pay for the services.
Authorization: An approval from your health plan for a specific service, usually within a certain window of time. Many plans, including HMOs, require authorizations for all specialist services/procedures.
Primary Care Physician: Health provider that cover a range of prevention, wellness, and treatment for common illnesses. Primary Care Physician include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.
Specialist: A physician that focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
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