Insurance basics
Understanding your child’s insurance
Deductibles, copays, referrals, EOBs: the words on an insurance card decide what a visit costs and who has to approve it. Here is what each one means, and how it works at Dare2Care Pediatrics.
Glossary
Insurance terms, in plain language
| Term | What it means | At Dare2Care Pediatrics |
|---|---|---|
| Premium | The monthly price of the plan, paid whether or not you use care | Medicaid and PeachCare for Kids have no or very low premiums |
| Deductible | What you pay for covered care each year before the plan starts paying | Preventive care (well visits, vaccines) is exempt on nearly every plan; sick visits and tests may count toward it |
| Copay (copayment) | A fixed amount for a visit, set by your plan and paid at the time of service | Collected at check-in; Medicaid and PeachCare for Kids visits for children have no copay for primary care |
| Coinsurance | A percentage of the bill you pay after the deductible, such as 20% | Applies mostly to tests and procedures; ask us for the code before an elective test |
| Out-of-pocket maximum | The most you pay in a year; after that the plan pays 100% | Family plans have one maximum for everyone on the policy |
| In-network | Providers who have a contract with your plan and agreed prices | We are in-network for the plans on our insurance page; the practice and each provider must be in the network |
| Out-of-network | Providers without a contract; you pay more, or everything | Kaiser, WellStar plans, Oscar and Anthem Blue Value Select are out-of-network with us |
| Primary care provider (PCP) | The doctor or practice your plan recognizes as your child’s home base | Required for Medicaid, PeachCare for Kids, HMO and POS plans; see choosing your PCP |
| Referral | Your PCP’s note that sends your child to a specialist; HMO and Medicaid plans require it | We write referrals and track that they were accepted |
| Prior authorization | The plan’s approval before certain tests, medicines or therapies are covered | Our team submits these; ADHD medicines and some imaging often need one |
| Explanation of benefits (EOB) | The plan’s statement of what was billed, what it paid and what you owe; it is not a bill | Compare it with our statement; call us if they do not match |
| Preventive care | Well visits, vaccines and screenings covered at no cost under the Affordable Care Act | Every well visit from birth through 21, and all routine vaccines |
| Sick visit (problem visit) | A visit for an illness or concern, billed separately from preventive care | A concern raised during a well visit may add a problem-visit charge; we tell you first |
| Care management organization (CMO) | The managed-care plan that runs Georgia Medicaid benefits | Amerigroup Community Care, CareSource and Peach State Health Plan |
| PeachCare for Kids | Georgia’s low-cost coverage for children in families who earn too much for Medicaid | Runs through the same four plans; we accept it |
| Katie Beckett (TEFRA) | A Medicaid pathway for children with significant disabilities regardless of family income | We complete the medical forms and accept the resulting Medicaid coverage |
| Vaccines for Children (VFC) | A federal program providing free vaccines to uninsured, underinsured and Medicaid-enrolled children | We are a VFC provider |
| Telehealth coverage | Whether a video visit is paid like an office visit | Covered by Georgia Medicaid and most commercial plans; ask us if unsure |
How a visit is billed
From check-in to the statement
- At check-in we verify eligibility and collect the copay your plan sets.
- After the visit we send a claim to your plan with the visit type and any tests.
- The plan applies your deductible, copay and coinsurance and pays its share, usually within two to four weeks.
- You receive an explanation of benefits from the plan and, if anything is left, a statement from us. The EOB is not a bill.
- Questions or a mismatch between the two: call the front desk and we go through it with you.
Preventive care and routine vaccines are covered at no cost by Medicaid, PeachCare for Kids and commercial plans. A concern discussed at a well visit, such as a rash or a behavior question, may be billed as a problem visit alongside it; we tell you when that happens.
Questions
Insurance questions families ask
Why did I get a bill for a well visit?
Usually because a separate concern was addressed at the same visit and billed as a problem visit, or because the plan applied a deductible to a test. Call us with the EOB and we will explain it line by line, and correct it if a code is wrong.
What if we lose coverage or switch plans mid-year?
Tell us before the next visit. We check eligibility at every check-in, and we can help families apply for Medicaid, PeachCare for Kids or marketplace coverage through Georgia Gateway.
Do you offer self-pay prices?
Yes. Ask the front desk for the current well-visit and sick-visit prices. Uninsured children can still get routine vaccines at no cost through the Vaccines for Children program.
Do I need to bring the card every time?
Bring it whenever the plan changes, and once a year otherwise. Medicaid and PeachCare for Kids cards should be brought to every visit because eligibility can change month to month.
Still have a question about coverage?
Call or text (770) 615-7000 with your plan name. We verify eligibility before every first visit and explain any cost up front.