Patient resources

Questions to ask your insurer

Call the member services number on the back of your insurance card and ask the questions below. We're here to help you make sense of the answers.

Starting February 1, 2027, Pearl Health will be out-of-network with all insurance plans.
Your plan
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What type of plan do I have: PPO, POS, HMO, or EPO?
PPO and POS plans usually include out-of-network benefits. HMO and EPO plans usually do not.
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Do I have out-of-network benefits?
Your costs
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What is my out-of-network deductible, and how much of it have I met this year?
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What is my coinsurance for out-of-network care?
This is the percentage you pay after your deductible is met.
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What is my out-of-network out-of-pocket maximum?
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How do you determine the “allowed amount” for out-of-network providers?
Insurers reimburse based on their allowed amount, not the provider's fee. Any difference is your responsibility.
Your care
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Is reproductive health evaluation and treatment covered, including care for underlying causes?
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Is gynecologic surgery (such as laparoscopy) covered out-of-network?
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Do I need preauthorization for surgery or other procedures, and who is responsible for requesting it?
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Are lab work and imaging covered?
These are often billed separately by the lab or imaging center. Ask whether those facilities are in-network.
Getting reimbursed

After February 1, Pearl will provide free access to Reimbursify, an easy-to-use app that submits your out-of-network claims to your insurer for you, at no cost to you. Ask your insurer:

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What is the deadline to submit an out-of-network claim?
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How long does reimbursement usually take, and how will it be paid to me?
Other options

Beyond traditional insurance

Health care sharing ministries

Health care sharing ministries are communities of members who share one another's medical expenses, usually around a common faith. They are not insurance. They are not regulated as insurance in Texas, and payment of any medical expense is not guaranteed. For many families, though, they pair well with a self-pay practice like Pearl.

Examples include Christian Healthcare Ministries, Solidarity HealthShare, and Samaritan Ministries.

Questions to ask a ministry:

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Is reproductive health evaluation and treatment eligible for sharing, including care for underlying causes?
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Are surgeries for conditions such as endometriosis eligible?
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How are pre-existing conditions handled? Is there a waiting period?
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What is my annual “unshared amount”?
This works much like a deductible: the amount you pay before sharing begins.
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Do I pay the provider up front and request reimbursement, or does the ministry pay directly?
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Do I need to notify the ministry before surgery or a major procedure?
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Are there limits per need, per year, or over my lifetime?
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Are pregnancy and maternity expenses shared? Is there a waiting period?
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What are the membership requirements (statement of faith, lifestyle commitments)?
Non-ACA-compliant health plans

Some insurers offer plans outside the Affordable Care Act marketplace, such as Presidio Healthcare. These plans often cost less and may include out-of-network benefits, but they don't have to follow ACA rules. They may decline or limit coverage for pre-existing conditions, cap benefits, or exclude maternity care. Read the plan documents carefully and ask the same questions as above.

If you're changing coverage

Employer and Marketplace open enrollment typically happens in the fall, so check your deadlines soon. Many health sharing ministries accept members year-round. Avoid a gap: keep your current coverage until your new coverage begins.

How Pearl will help

• A clear estimate of your costs before your care, so there are no surprises.

• Free access to Reimbursify, an easy-to-use app that submits your insurance claims for you.

• A team ready to walk through your situation with you.

Questions? Call 214-307-7799, email info@pearlhealthdallas.com, or message us through the patient portal.

This guide is for general information only. Plans named are examples; Pearl Health does not endorse any specific insurance plan or health sharing ministry. Please confirm all details directly with your plan.

Next step

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