Insurance Plans and Coverage Types Accepted

In-Network

• Aetna CVS Health
• Anthem BCBS – Pathway & Pathway X (For services at MO locations only) 
• Balance by Medica
• BCBS of Kansas - BlueCare & Blue Choice 
• BlueKC (BlueSelect Plus & Preferred Care Blue)
• Medica (Medica with MU HealthCare & Select by Medica) 

Out-of-Network

• Ambetter from Home State Health (Missouri) 
• Ambetter from Sunflower Health Plan (Kansas)
• Blue KC BlueSelect
• Cox Health EPO
• Oscar Health
• United Healthcare ACA Exchange (Gold, Silver, Bronze)
• Well First by Medica (offered in St. Louis)

  What if I have an Out-of-Network plan?  

Commercial

• Aetna
  • CareLink 
  • CVS Caremark
  • Meritain
• American Healthcare Alliance
• Anthem BCBS of Missouri (utilizing BlueKC network)
• Ascension Health Plan (utilizing BlueKC network)
  • US Health & Life-Ascension Personalized Care EPO (Out-of-Network)
• BlueKC
  • Blue Access (Out-of-Network)
  • BlueCard PPO (plans with PPO suitcase on ID card)
  • BlueSelect (Out-of-Network)
  • BlueSelect Plus
  • High Performance Network
  • Freedom
  • Freedom Network Select
  • Preferred Care
  • Preferred Care Blue
  • Preferred Health Professionals
• BCBS of Kansas BlueChoice Solutions
• Cigna
  • Cigna + Oscar
  • Cigna Plus
  • Cigna SureFit
  • Great-West Healthcare
  • HealthPartners
  • LocalPlus or LocalPlusIN
  • MVP Health Care
  • Network Open Access
  • Open Access Plus
  • PriorityHealth
  • Tufts Health Plan
• Centivo Network
• CoxHealth Network
  • EPO Exchange (Out-of-Network)
• CoxHealth Plans (utilizing First Health Network)
• FAIROS (powered by OccuNet)
• First Health Network (excluding all health and/or cost sharing ministries)
• GEHA (utilizing UHC network)
• HealthLink HMO & Open Access
• HealthLink PPO (utilizing Freedom Network)
• Humana
• Medica
  • Balance by Medica
  • Medica with MU Health Care (referral required)
  • Select by Medica
  • WellFirst by Medica (offered in St Louis Metro)
• Mercy Health Springfield Communities
• MultiPlan (excluding all health and/or cost sharing ministries)
• National Preferred Provider Network
• PHCS (excluding all health and/or cost sharing ministries)
• ProviDRs Care (formerly WPPA)
• QuikTrip
• United Healthcare (UHC)
  • ACA Exchange [Gold, Silver, Bronze] (Out-of-Network)
  • All Savers
  • Custom Network Plan (Out-of-Network)
  • Deere Premier (Out-of-Network)
  • Surest (limited benefit coverage)
  • UHC Core Essential
  • UHC Choice & Choice Plus
  • UHC Navigate
  • UHC NexusACO
  • UHC Options
  • UHC Select
  • UMR
• USA Managed Care Organization
• WellFit Health

Federal Plans

• Tricare 
  
  • Prime plans require a PCM referral 

Medicare Advantage (MA) Plans

As a pediatric health system, Children’s Mercy Kansas City does not contract or participate with any Medicare Advantage  plans.

State Medicaid Plans

If you have Medicaid coverage and do not live in Kansas or Missouri, please contact your State Medicaid Agency or Health Plan to verify that Children’s Mercy Kansas City is authorized to provide care to your child prior to seeking services. Many States have special requirements that need to be followed before seeking services from an out of State provider and if these are not followed you may not have coverage and be financially responsible for the care you receive at Children’s Mercy Kansas City. The phone number to call for this information should be located on your benefit card that is provided by your State Medicaid Agency or Health Plan when you become eligible for Medicaid coverage.

• Arkansas Medicaid/ARKids First (referral required)
  • Provider-led Arkansas Shared Shavings Entity (PASSE) 
    • Arkansas Total Care (Out-of-Network)
    • CareSource (Out-of-Network)
    • Empower Healthcare Solutions (Out-of-Network)
  • Summit Community Care (Out-of-Network)
• Oklahoma Medicaid/SoonerCare (referral required)
  • Oklahoma Medicaid SoonerSelect - Plans
    • Aetna Better Health (Out-of-Network)
    • Humana Healthy Horizon (Out-of-Network)
    • Oklahoma Complete Health (Out-of-Network)

Kansas and Missouri Medicaid Managed Plans

• Kansas
  • Healthy Blue Kansas
    • SkyGen USA Dental
    • EyeMed Vision
  • Sunflower Health Plan
    • Envolve Dental
    • Envolve Vision
  • United Healthcare Community Plan of Kansas
    • Dental Benefit Providers
    • MARCH Vision Care 
      
      
• Missouri
  • Healthy Blue of Missouri
    • DentaQuest
    • MARCH Vision Care
  • Home State Health/ Show Me Healthy Kids
    • Envolve Dental
    • Envolve Vision
  • United Healthcare Community Plan of Missouri
    • Dental Benefit Providers
    • MARCH Vision Care

Specialty Networks

Mental and Behavioral Health

• Cenpatico
• Evernorth Behavioral Health (formerly Cigna Behavioral Health)
• Lucet Behavioral Health (formerly New Directions)
• Optum / United Behavioral Health

Centers of Excellence - Transplant Networks

• Aetna Institutes of Excellence (IOE)
  • BMT, Heart, Kidney
• Blue Distinction Centers for Transplant (BDCT)
  • BMT, Heart
• Cigna LifeSOURCE Transplant Network Designated Programs
  • BMT, Kidney 
• Humana National Transplant Network  
  • BMT, Kidney 
• LifeTrac/Emerging Therapy Solutions (ETS) Programs of Excellence
  • BMT, Heart, Kidney,
• Optum Pediatric Transplant Centers of Excellence (COE) Network
  • BMT, Heart, Kidney

Dental

• Delta Dental
• DentaQuest 
• Envolve Dental
• MetLife
• SkyGen USA (formerly Scion Dental)

Vision

• Envolve Vision/Opticare
• EyeMed Vision
• MARCH Vision Care
• SkyGen USA (formerly Ocular Benefits)
• Vision Service Plan (VSP)

A narrow network is a type of health plan that requires members to receive care in their preferred, narrow network of a select group of doctors, hospitals, outpatient facilities, laboratories, etc.

• Aetna KC Care Network Plus (formerly I-35 Preferred)
  • Adult Health System Network: AdventHealth Shawnee Mission, KU Medical Center, Liberty Hospital, HCA MidWest Health, North Kansas City Hospital, Olathe Health, University Health
• Aetna Connected
  • Adult Health System Network: AdventHealth Shawnee Mission, KU Medical Center, Liberty Hospital, HCA MidWest Health, North Kansas City Hospital, Olathe Health, University Health
• BlueKC High Performance Network
  • Adult Health System Network: Saint Luke’s Health System
• Cigna Sure Fit
  • Adult Health System Network: HCA MidWest Health, North Kansas City Hospital
•  Cigna Local Plus
  • Adult Health System Network: HCA MidWest Health, North Kansas City Hospital
• UHC Core Essential
• • Adult Health System Network: Saint Luke’s Health System
    
    

Medical

• Ambetter from HomeState Health Plan (Missouri)
• Ambetter from Sunflower Health Plan (Kansas)
• Anthem Pathway/Pathway X (KS locations only)
• Arkansas Medicaid Provider-Led Arkansas Shared Savings Entity (PASSE) 
  • Arkansas Total Care
  • CareSource
  • Empower Healthcare Solutions
  • Summit Community Care
• Ascension Personalized Care EPO
• Aspen STM (All Hospital/Facility Services)
• BlueKC Blue Access 
• BlueKC Blue Select
• Cox Health EPO
• Custom Network Plans (Administered by United Healthcare)
  • Custom Network Plan
  • Deere Premier
• HealthChoice of Oklahoma 
• Kaiser Permanente
• LifeShield STM (All Hospital/Facility Services)
• MedBen
• Mercy Anthem Alliance EPO (Anthem BCBS) 
• Oklahoma Medicaid SoonerSelect (Managed Medicaid plans Only)
  • Aetna Better Health of Oklahoma
  • Humana Healthy Horizon
  • Oklahoma Complete Health
• Oscar Health
• PHCS Practitioners Only (All Hospital/Facility Services)
• Preferred CommunityChoice
• Prime Health Services (PHS)
• United Healthcare ACA Exchange [Gold, Silver, Bronze]
• US Health & Life - Ascension Personalized Care EPO 
• Vālenz Health 
• Walmart / Mercy: Arkansas Local Plan & Southwest Missouri Local Plan
• Well First by Medica (offered in St. Louis)
• All other Medicaid and Managed Medicaid plans outside of the states of Arkansas, Kansas, Missouri, and Oklahoma.

Mental and Behavioral Health

• Beacon Health Options (formerly Value Options)
• Magellan Healthcare
• Mercy Managed Behavioral Health

Dental

• Aflac Dental
• Oklahoma Medicaid SoonerSelect Dental Plans
  • DentaQuest
  • LIBERTY Dental
• United Concordia Dental

Home Care

• Humana

Therapy

• TheraMatrix (BCBS of Michigan)

Vision

• Vision Care Direct

  What if I have an Out-of-Network plan?  

The No Surprises Act defines an uninsured individual as:

• A patient who has no insurance and is self-pay.
• A patient who has a short-term medical plan.
• A patient who has a cost share or ministries sharing group coverage.
• A patient who has a limited benefits plan.

What is a cost or health care sharing plan?
A cost share or health care sharing plan is provided by organizations whose members “share” medical costs. As part of a health care sharing plan, you are responsible for paying certain share amount each month (like a premium) as well as an “annual unshared amount” for your own expenses (like a deductible) that your medical expenses must exceed before the plan shares your expenses. 

Does Children’s Mercy accept cost sharing plans?
Per the No Surprises Act, individuals with a cost share or health care share plan are uninsured. Therefore, any patient who is enrolled in a sharing plan will be identified as self-pay, or uninsured, when seeking care at Children’s Mercy. Within three days of your appointment being scheduled, a member of Children’s Mercy’s Financial Clearance team will call you to provide a good faith estimate for services the child may receive as part of the scheduled appointment.  

How does billing work if I have a cost share plan?
You will receive a statement for services received with the appropriate self-pay discount already applied. You may forward your statement to your cost share group for review and reimbursement, but you are ultimately responsible for payment regardless of whether your cost share group reimburses you or not. Please note, Children’s Mercy will not send a claim or statement to the cost share group directly; it is your responsibility to submit to your cost share group.

The No Surprises Act defines an uninsured individual as:

• A patient who has no insurance and is self-pay
• A patient who has a short-term medical plan
• A patient who has a cost share or ministries sharing group coverage
• A patient who has a limited benefits plan

Can my child be scheduled for an appointment if they do not have insurance?

Yes! Within three days of your appointment being scheduled, a member of the Children’s Mercy’s Financial Clearance team will call you with a good faith estimate for the services the child may receive as part of the scheduled appointment.

If my child does not have insurance, how can they get coverage?

• You can enroll in the health care exchange during the open enrollment period, or if you meet the definition of a life event at healthcare.gov.  
• Review the information on this page to confirm what exchange plans are in-network with Children’s Mercy
• You can contact a Children’s Mercy Financial Counselor for help enrolling/applying for insurance. A counselor can also screen you for one of Children’s Mercy’s financial aid programs.

How much will I owe if my child does not have insurance?

Families who are defined as uninsured will be eligible for the self-pay discounted rate. You can run a patient estimate for services that your child may receive.

If your insurance card references any of the terms listed below, you likely have limited coverage at Children’s Mercy for the services your child may need

• Practitioner Only
• Ancillary Services
• Hospital/Facility Based Charges
• Referenced Based Pricing or Accepting Medicare Rates

Typically, these plans will only cover the office visit with a doctor or nurse practitioner, but no additional services outside of meeting with the provider.  Children’s Mercy bills as an outpatient hospital, which means that services are most likely not covered at all, or have very limited coverage. To avoid paying higher out-of-pocket costs, contact your health plan to ask where you child can receive care that will be covered by your insurance plan. If there is not another provider that your plan will cover, ask your plan how you can seek approval to have these services at Children’s Mercy.

To ensure your child’s services will be covered by your insurance plan, follow the OON Appointment Request process.

Examples of Hospital Based Charges that will most likely not covered by a Practitioner Only plan:

Diagnostic testing: Any lab, radiology, blood/urine/saliva lab, genetic testing, X-rays, ultrasounds, CT/MRI’s, IVR’s PET scans, nuclear medicine studies, echocardiograms, sleep studies, EEG’s, allergy testing, and/or development, behavioral, or psychology testing

Therapy services: New/established patient evaluations or therapy/services with a physical therapist, occupational therapist, speech therapist, audiologist, or development/behavioral or psychological services

Medications: Including but not limited to oral, injected, infused medications or implants

In-office or surgical procedures: Circumcisions, bone/fracture care, laser procedures, colonoscopies, or any services in an operating room, procedure room, or in a clinic

Facility charges: including Inpatient or Observation stay, and ground/air ambulance

*This list is not an all-inclusive list. Please email  NarrowNetwork@cmh.edu for questions related to specific services.