Insurance

• Understand Your Insurance Plan's Benefits

  Understand if your plan has any:

  • Restrictions or limits in coverage
  • Non covered services (some of the following may be considered as “not covered” by some plans: telehealth, testing, immunizations, etc.)
  • Out-of-Network benefits
  • Special criteria for use with physicians and other services provided in the Clinic
  • Pre-authorization requirements

• Benefits for Prescription Drugs and Immunizations

  Deciphering insurance coverage can be confusing. There are many plan types, and each has its own guidelines for covered services (hospitals, doctors, prescriptions, etc.). In general, MCH (Clinic) is allowed to bill Medicare Part B insurance for physician interactions and some diagnostic services (although Laboratory tests may be billed by MCH’s Laboratory entity as opposed to the Clinic entity).

  Here’s a quick summary of Medicare options:

  • Part A (Hospitals): covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services.
  • Part B (Doctors): covers outpatient doctor visits, some preventive services, durable medical equipment (DME), and some home health services (Lab tests are usually billed under Part B by our MCH Laboratory entity, not under our Clinic/provider NPI [National Provider Identifier]).
  • Part D (Prescription Drug benefit): covers certain prescription drugs through private insurance companies approved by Medicare.  Pharmacies typically bill Part D for prescriptions and most immunizations. Neither MCH nor our physicians are allowed to bill Medicare Part D, although some exceptions exist based on coverage and frequency, (i.e., annual flu shots can be billed by MCH thorough Part B).

  Here’s how to be a savvy healthcare consumer:

  • Be Proactive: Don’t wait until you need care. Ask questions beforehand!
  • Know Your Resources:
  • Summary of Benefits and Coverage (SBC): This document explains your plan’s coverage details. Get a copy from your insurer and use it as a reference.
  • Customer Service:
    • Insurance: Call your insurance company’s customer service for specific coverage details related to your plan.
    • Contact your healthcare provider’s billing department: inquire if they are “in-network” with your plan and confirm coverage for your upcoming visit

    Additional Tips:

  • Explanation of Benefits (EOB):
    • After a medical visit, you’ll receive an EOB explaining the charges, your insurance contribution, and any remaining patient responsibility. Review it carefully and contact your insurer if you have questions.
  • Price Transparency Tools:
    • Some plans offer online tools to estimate costs for specific services at certain locations. Utilize these tools for budgeting healthcare expenses.

  By following these tips, you can gain a clearer understanding of your insurance coverage and make informed decisions about your healthcare.

• Communicate Your Insurance Plan's Benefits

  We encourage you to communicate directly with your employers’ human resource / benefits manager or your health insurance company’s help desk to understand the details of your coverage.

  Please relay these details to your MCH physicians’ staff.

  If you have additional questions after conferring with your health insurance company, please call MCH at  (713) 520-4713.

Participating Insurance Plans

• Aetna Plans

  • • • HMO
      • QPOS
      • Elect Choice
      • Managed Choice POS
      • Choice POS II
      • Select
      • Open Access
      • Open Choice PPO
      • National Advantage
      • EPO Standard Plans (No Limited EPO Plans from Memorial Hermann)

  To verify plan participation please call (713) 520-4713

• Anthem (Blue Cross Blue Shield) Plans

  • • • POS
      • PPO
      • EPO

  If a suitcase icon with the word PPO is displayed on the back on your insurance card, MCH physicians are participating physicians.

  What is the “PPO in a suitcase” logo?
  You’ll immediately recognize BlueCard PPO members by the special “PPO in a suitcase” logo on their membership card. BlueCard PPO members are Blue Cross and Blue Shield members whose PPO benefits are delivered through the BlueCard Program. It is important to remember that not all PPO members are BlueCard PPO members, only those whose membership cards carry this logo. Members traveling or living outside of their Blue Plan’s area receive the PPO level of benefits when they obtain services from designated PPO providers.

  To verify plan participation please call (713) 520-4713

• Blue Cross Blue Shield Plans

  Blue Cross Blue Shield of Texas – including Anthem

  (Call for other states)

  • • • HealthSelect  (your insurance card must show your MCH physician as your assigned PCP)
      • PPO
      • POS
      • ParPlan

  If a suitcase icon with the word PPO is displayed on the back on your insurance card, MCH physicians are participating physicians.

  What is the “PPO in a suitcase” logo?

  You’ll immediately recognize BlueCard PPO members by the special “PPO in a suitcase” logo on their membership card. BlueCard PPO members are Blue Cross and Blue Shield members whose PPO benefits are delivered through the BlueCard Program. It is important to remember that not all PPO members are BlueCard PPO members, only those whose membership cards carry this logo. Members traveling or living outside of their Blue Plan’s area receive the PPO level of benefits when they obtain services from designated PPO providers.

  To verify plan participation please call (713) 520-4713.

• Cigna Plans, effective June 15, 2021

  • • • HMO
      • Open Access Plan
      • Open Access Plus ONLY
      • Open Access Plus/Carelink
      • POS
      • PPO

  To verify plan participation please call (713) 520-4713.

• Humana Plans

  • • • Choice Care
      • POS
      • PPO
      • Preferred POS
      • Preferred PPO
      • NPOS Open Access

  To verify plan participation please call (713) 520-4713

• PHCS Multi Plan

  • • • POS
      • PPO

  To verify plan participation please call (713) 520-4713

• United Healthcare Plans

  • • • Choice
      • Choice Plus
      • PPO
      • Select
      • Select Plus
      • EPO (Navigate PCP requires a designated MCH Physician)

  To verify plan participation please call  (713) 520-4713.

• Medicare

  • • • Traditional Medicare
      • Medicare Railroad
      • Aetna Teachers’ Retirement Medicare Advantage plan (TRS.MA), effective January 1, 2013

  MCH physicians have chosen to be in the participating category of physicians in the above programs, which means your MCH physician will accept Medicare assignment.

  Traditional (also known as Original)  Medicare is a health insurance program administered by the U.S. government for people age 65 or older and for some disabled persons under 65. It is divided into two parts: hospital insurance (Part A) and medical insurance (Part B). We bill Part B insurance when services are rendered at the Clinic or by a Clinic physician.

  It is important for you to know that Medicare does not pay for all services provided at the Clinic. Medicare may determine your diagnosis does not qualify for coverage for certain procedures (e.g., limited coverage procedures) or that you have had a test too recently.  You may be asked to sign a waiver (i.e., a Medicare Advanced Beneficiary Notice [“ABN”]) stating that you will be responsible for payment should Medicare deny payment.

  Medicare does not pay for “non-covered” services, which are services that fall outside of the Medicare program. Physicians, whether “participating” or “non-participating,” can bill their usual fee for non-covered services. You will be responsible for full payment of non-covered services.

  Medicare Annual Exams:  Medicare makes a distinction between what it calls a “wellness visit’ and the kind of exam most of us think of as a “physical.”

• Insurance Plans: MCH NOT Participating

  We are NOT contracted with the following insurance plans.

  • • • HealthSmart Preferred Care
      • Most Qualified Health Plans (QHP) i.e., plans offered through the healthcare exchange
      • Most HMO plans
      • Most Medicare Advantage plans (as of April 2024, we will no longer be in-network with Devoted Health Medicare Advantage plans)

  You may see your MCH physician under your “out-of-network” benefits, please speak with your physician’s secretary to discuss.

Additional insurance details

• Traditional Indemnity Insurance and Self-Pay

  Payment of applicable deductibles should be made at the time of your visit. We will submit a claim to your insurance (primary and secondary if applicable) carrier for direct payment to the Clinic of your insurance benefits.

  We make every effort to be aware of obligations under your plan for pre-authorization, referral authorizations, and other utilization management obligations in order to be able to provide the services you need based on your health status. Since your insurance policy is a contract between you and your insurance carrier, we do not guarantee payment of your claim, nor do we assume responsibility for meeting your insurance plans’ requirements for pre-authorizations, second opinions, or hospital stays.

  We will, of course, be happy to furnish you with any documentation needed to obtain necessary approvals or to resolve a disputed claim.

  Should you being paying cash, we accept payment by cash, check, VISA, Master-Card, Discover, and American Express for services rendered at the time of your visit.

• PPO and POS Plans

  Payment of applicable deductibles and co-pays should be made at the time of your visit. We will submit a claim to your insurance (primary and secondary if applicable) carrier for direct payment to the Clinic of your insurance benefits. We make every effort to be aware of obligations under your plan for pre-authorization, referral authorizations, and other utilization management obligations in order to be able to provide the services you need based on your health status.

  Your awareness of your plan’s requirements will add a greater level of assurance that your plan’s obligations will be met which, in the long run, will benefit you. It is important for you to know that your insurance plan may not pay for all services provided at the Clinic. What services are covered is dependent on your plan’s benefits. You will be responsible for all services rendered that are considered non-covered, experimental, or deemed by your insurance company as not medically necessary.

• HMO and Gated Plans

  If your health plan requires you to select a primary care provider (“PCP“) please contact your Plan Administrator to designate your MCH general internal medicine physician as your PCP at least 24 hours in advance of your visit.

• Medicare

  Original (often called traditional) Medicare is a health insurance program administered by the U.S. government for people age 65 or older and for some disabled persons under 65. It is divided into two parts: hospital insurance (Part A) and medical insurance (Part B). We bill Part B insurance when services are rendered at the Clinic or by a Clinic physician.

  MCH physicians have chosen to be in the participating category of physicians in the Original Medicare program, which means your MCH physician will accept Medicare assignment.

  It is important for you to know that Medicare does not pay for all services provided at the Clinic. Medicare may determine your diagnosis does not qualify for coverage for certain procedures (e.g., limited coverage procedures) or that you have had a test too recently. You may be asked to sign a waiver [i.e., a Medicare Advanced Beneficiary Notice (“ABN”)] stating that you will be responsible for payment should Medicare deny payment.

  Medicare also does not pay for “non-covered” services, which are services that fall outside of the Medicare program. Physicians, whether “participating” or “non-participating,” can bill their usual fee for non-covered services. You will be responsible for full payment of non-covered services.

• Medicare Replacement Plans (Medicare Advantage)

  Medicare Advantage plans, offered through various insurance companies, are NOT considered traditional Medicare.  

  The Clinic does NOT participate in most Medicare Advantage (HMO or PPO) plans or accept Medicare Advantage patients, although you can see your MCH physician under your “out-of-network” benefits*.

  MCH physicians are no longer accepting Devoted Health Medicare Advantage plans (Core Greater Houston HMO Plan and Prime Greater Houston HMO Plan) as MCH will no longer be in-network with Devoted as of April 2024.

  *Should you have a Medicare Advantage PPO plan (i.e., *Teachers’ Retirement Medicare Advantage plan “TRS.MA”), please call and discuss your specific situation with your MCH physician.