Insurance Plans and Coverage Types Accepted

• Aetna CVS Health
• Ambetter from HomeState Health (Out-of-Network)
• Ambetter from Sunflower Health Plan (Out-of-Network)
• Anthem BCBS – Pathway & Pathway X (Out-of-Network at CM KS locations)
• BCBS of Kansas – BlueCare & Blue Choice
• BlueKC
  • BlueSelect (Out-of-Network)
  • BlueSelect Plus
  • Preferred Care Blue
• CoxHealth Network EPO Exchange (Out-of-Network)
• Medica
  • Balance by Medica
  • Medica with MU Health Care (referral required)
  • Select by Medica
  • WellFirst by Medica (offered in St Louis Metro (Out-of-Network)
• Oscar Health (Out-of-Network)
• United Healthcare ACA Exchange (Out-of-Network)

• Aetna
  • CareLink 
  • CVS Caremark
  • Meritain
• American Healthcare Alliance
• Anthem BCBS of Missouri
• Anthem Alliance Options PPO
• Anthem Blue Access PPO (Out-of-Network)
• BCBS of Kansas
• BlueKC
  • Blue Access (Out-of-Network)
  • BlueSelect (Out-of-Network)
  • BlueSelect Plus
  • High Performance Network
  • Freedom Network
  • Freedom Network Select
  • Preferred Care
  • Preferred Care Blue
  • Preferred Health Professionals
• Cigna
  • SureFit
  • Great-West Healthcare
  • HealthPartners
  • LocalPlus or LocalPlusIN
  • MVP Health Care
  • Network Open Access
  • Open Access Plus
  • PriorityHealth
  • Tufts Health Plan
• Centivo Network
• Centrus Health Direct (HCH Sync Centrus)
• CommunityCare (Out-of-Network)
• CoxHealth Network
• CoxHealth Plans (utilizing First Health Network)
• FAIROS (powered by OccuNet)
• First Health Network (excluding all health and cost sharing ministries)
• GEHA (utilizing UHC network)
• Health Choice of Oklahoma (Out-of-Network)
• HealthLink HMO & Open Access
• HealthLink PPO (utilizing Freedom Network)
• Kaiser Permanente (Out-of-Network)
• Mercy Health Springfield Communities
• MultiPlan/Claritev (excluding all health and cost sharing ministries)
• National Preferred Provider Network (NPPN)
• PHCS (excluding all health and cost sharing ministries)
• PHCS Practitioners Only (Out-of-Network)
• Preferred CommunityChoice (Out-of-Network)
• Prime Health Services (PHS) (Out-of-Network)
• ProviDRs Care (formerly WPPA)
• QuikTrip
• TheraMatrix (Out-of-Network)
• United Healthcare (UHC)
  • 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
• Vālenz Health (Out-of-Network)
• Wachter
• WellFit Health

Medicaid & Managed Medicaid Plans

• Arkansas
  • ARKids First (referral required)
  • Provider-led Arkansas Shared Savings Entity (PASSE)
    • Arkansas Total Care (Out-of-Network)
    • CareSource (Out-of-Network)
    • Empower Healthcare Solutions (Out-of-Network)
    • Summit Community Care (Out-of-Network)
• Kansas
  • KanCare
    • Healthy Blue Kansas
    • Sunflower Health Plan
    • United Healthcare Community Plan of Kansas
• Missouri
  • MO Healthnet
    • Healthy Blue Missouri
    • Home State Health / Show Me Healthy Kids
    • United Healthcare Community Plan of Missouri
• Oklahoma
  • SoonerCare (referral required)
  • SoonerSelect
    • Aetna Better Health (Out-of-Network)
    • Humana Healthy Horizons (Out-of-Network)
    • Oklahoma Complete Health (Out-of-Network)
• All Other State Medicaid Plans not listed above (Out-of-Network)

Medicare Advantage (MA) Plans

• As a pediatric health system, Children’s Mercy Kansas City does not contract or participate with any Medicare Advantage plans. (Out-of-Network)

Tricare

• Prime plans require a PCM referral.

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

• Carelon Behavioral Health (Out-of-Network)
• Evernorth Behavioral Health
• Lucet
• Magellan Health (Out-of-Network)
• Optum / United Behavioral Health

• Aflac Dental (Out-of-Network)
• Argus Dental (Out-of-Network)
• Delta Dental
• DentaQuest
  • Missouri Medicaid - Healthy Blue Missouri
  • Oklahoma Medicaid - (Out-of-Network)
• Dental Benefit Providers
  • Kansas Medicaid - United Healthcare Community Plan of Kansas
  • Missouri Medicaid - United Healthcare Community Plan of Missouri
• Dentegra (Out-of-Network)
• Envolve Dental
  • Kansas Medicaid – Sunflower Health Plan
  • Missouri Medicaid - Home State Health / Show Me Healthy Kids
• GEHA Connection Dental (Out-of-Network)
• Liberty Dental (Out-of-Network)
• MetLife
• Principal Plan Dental (Out-of-Network)
• SkyGen USA Dental (formerly Scion Dental)
  • Kansas Medicaid - Healthy Blue of Kansas
• United Concordia Dental (Out-of-Network)
• Unum Dental (Out-of-Network)

• Envolve Vision
  • Kansas Medicaid - Sunflower Health Plan
  • Missouri Medicaid - Home State Health / Show Me Healthy Kids
• EyeMed Vision
  • Commercial
  • Kansas Medicaid - Healthy Blue of Kansas
  • Missouri Medicaid - Healthy Blue Missouri
• MARCH Vision Care
  • Kansas Medicaid - United Healthcare Community Plan of Kansas
  • Missouri Medicaid - United Healthcare Community Plan of Missouri
• Vision Care Direct (Out-of-Network)
• Vision Service Plan (VSP)

If you have questions regarding your pharmacy benefits or prescription coverage, please contact your pharmacy benefit manager (PBM) directly.

Your PBM may be listed on your health plan card, or a separate prescription card may have been provided to you.

• Blue Eagle Health
• Capital Rx
• Caremark
• Elixir
• Employee Health Insurance Management
• Express Scripts
• Gateway
• Humana
• Independent Health
• Liviniti
• Magellan Rx Management
• MaxCare
• MaxorPlus
• MedImpact
• MedOne
• Navitus
• Optum Rx
• PerformRx
• Pharmacy Data Management, Inc.
• Prescryptive
• ProCare Rx
• Providence Health
• Rightway
• RxAdvance
• RxSense
• Sav-Rx
• Script Care
• ScriptClaim
• Select Health
• Serve You
• SmithRx
• SS&C
• Tredium
• Ventegra
• WellDyne

• What if I have an Out-of-Network plan?
• Out-of-pocket cost comparison for in network vs. out of network
• Contact an insurance navigator
• Kansas Insurance Department
• Missouri Department of Insurance

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.