With the start of 2020 well underway, many insurance plans start a new benefit year which can mean patients and their families have deductibles and out-of-pocket maximums to meet. Parents are sometimes surprised when they get a bill from their pediatrician’s office for part – or all – of their child’s well visit. We are of course happy to review the billing record for any errors, but below we have outlined just a few common reasons you might receive a bill after your child’s well visit:

Reason 1: Your child’s insurance plan is not ACA-compliant.

• While new group health plans and exchange plans are required to cover all parts of the well child visit with no cost sharing, many health insurance plans are exempt from the ACA (Affordable Care Act) and, as a result, this requirement. These include existing unchanged health plans from before the ACA became law (“grandfathered” plans), government plans like Tricare or ChampVA, and membership plans like faith-based cost-sharing services.

Reason 2: Your child’s insurance plan is ACA-compliant, but you received some preventive services which are not part of the ACA-recommended list.

• The US Preventive Services Task Force puts out a list of services that ACA-compliant plans are expected to cover, found here.
• For example, routine vaccines (not travel vaccines) are on the list of covered preventive services. If a child received a travel vaccine as a part of a well-child visit, an ACA-compliant plan may not fully cover the cost of the travel vaccine, even though it is a preventive service.

Reason 3: Your child’s insurance plan is ACA-compliant, but you received some non-preventive services as a part of the visit.

• For example, lung function testing for asthma or an evaluation of chronic headaches might be done at a well-child visit. While both services help promote wellness, neither are included in the definition of a standard well-child visit service and may result in an additional charge based on the rules of your insurance plan. Some families only want covered preventive services at a well child visit while other families appreciate that a pediatrician can provide all the needed services at the same time, so you don’t have to come back for a separate visit. If you have questions about your child’s well visit, call our office and our nursing staff can speak with you about your child’s health concerns.

Reason 4: Your child’s insurance plan is ACA-compliant, but you received more frequent services than is typical.

• This occurs when well-child visits are scheduled closer together than what your insurance company considers to be “annual.” Some insurance companies pay for one well-child visit per calendar year. This means a child might have a check-up in September one year and July the next. Other insurance companies have more stringent rules and say that at least 365 days must pass between well exams. If not, the second well visit will be denied by your insurance company, and you will be responsible for the charges. Be sure you understand your insurance company’s definition of “annual” before scheduling the appointment.

Reason 5: Your child received ACA preventive services, but your insurance company does not recognize the billing codes your pediatrician used for that service.

• For example, vision screening for children ages 3 to 5 is an ACA preventive service. There are three codes commonly used to report vision screening in children: simple eyechart and two types of electronic instruments.
  • Some insurance plans recognize the eyechart code as an ACA code, but not the electronic instrument code. In that case, a family would have no cost-sharing responsibility for an eye chart, but they would if their child could not use the eye chart, and the pediatrician screened vision using an electronic instrument. Families might ask the pediatrician’s office to use the covered code – even if they pediatrician preformed the service using the other method. However, it is a violation of insurance contracts and federal and state laws to knowingly report the wrong code.
  • Other insurance plans might permit all the vision screening codes as ACA preventive, but not accept them when billed by a pediatrician. The plan may only pay for them when the family makes a separate trip to an eye doctor.

Any balances left to your child’s account are determined by your insurance benefits. Becoming familiar with your insurance policy is important for each family. Contact your Human Resource department or the member services department at your insurance company and they can provide you with detailed benefit information.