Kids’ Health Insurance and the First Doctor’s Visit, and Where the $400 Bill Comes From

Names and identifying details of every student here are changed, as they are everywhere on the blog.

Olesya does not take her jacket off. She sits down, puts the bill on my station, smooths it flat with her palm, and waits. Four hundred and change, for a visit that the clinic told her was covered. Her son is four, the insurance is through her husband’s job, and the appointment was the ordinary yearly one.

She is not angry. She is scared, which is worse, because she has decided that this will now happen every time.

What the yearly visit actually is

Well-child visit, that is what it is called on the schedule, and the whole point of it is a child who is fine. Height and weight get measured. They check vision and hearing. They ask about development, give the shots that are due, and talk about sleep and eating. By the pediatric schedule most families follow, there are about 11 of them before a child turns two and a half, and then one a year from age 3 all the way to 21.

On a plan that follows the Affordable Care Act, and that is most employer and marketplace plans, the preventive part of that visit comes with no copay and no deductible, as long as the doctor is in network. This is the sentence the clinic told Olesya, and it was true.

So where does a bill come from

From the things that are not the preventive part. Pediatricians write about this directly, and the reasons are boring and specific.

1. The plan is not ACA-compliant, which happens with older grandfathered plans and some government and self-insured ones.
2. A service was done that is not on the preventive list for that age.
3. A service was done more often than the schedule expects.
4. A separate problem was handled at the same visit, which is billed as a sick visit on top of the well visit.
5. The insurer did not accept the code the office used for a service, which happens with screenings that have several codes for the same age.

Her bill was the fourth one on that list. She had mentioned, near the end, that the boy had been coughing for two weeks, and the doctor listened to his chest, asked questions, and wrote it up. Two visits on one afternoon, one of them free and one of them not.

A cough mentioned at the door can turn one appointment into two bills. Not a scam, just how the visit is written up.

Questions for the desk, and before it

Pediatric guidance says it plainly, ask the practice what its policy is on handling sick problems during a well visit. Some offices do both and bill both. Some tell you to come back. Neither is wrong, and knowing which one you are in front of is worth a phone call.

At the desk it is two questions. Is this doctor in network for our plan, and where do the labs go. That second one catches the bills nobody sees coming.

And if the cough is the actual reason you are going, book a sick visit instead of the yearly one. Same doctor, different appointment, and the yearly one stays clean for later.

One more thing about timing, because it catches people. Nothing arrives that same week, either. The claim goes from the office to the insurer, the insurer takes its time, and the envelope turns up four or six weeks after the appointment, once everybody has forgotten what was even said in that room. Write the date and the reason for the visit somewhere, even in your phone, and the call in November about an appointment in September stops being a guessing game.

Families on Medi-Cal

Different picture, and a better one. For children and teens under 21, Medi-Cal covers check-ups, screenings and the visits that go with them, and the federal rule behind it requires medically necessary care for children even where the adult program would not cover it.

Whether a family qualifies depends on income and household size, and in Los Angeles the county social services department is the place that sorts it out. Olesya’s family does not qualify. Her neighbor’s family does, and that neighbor had never opened the envelope because she assumed it cost money.

That neighbor did open it, eventually, and found the part about check-ups being covered for her daughter with no payment at the desk, and she cried about the two years she had skipped them. That is the other half of this subject, the families who are covered and do not know it.

Bills nobody expected

Call the billing office, not the insurance company, first. Ask for an itemized bill and ask which parts were billed as preventive and which as something else. Offices are supposed to review their own records for errors, and that review is the whole reason the call is worth making.

My first American bill was $60 for something I never understood, and I paid it in the parking lot on my phone because I was afraid. Six years later a client who works in medical billing told me how often a bill gets corrected when somebody simply calls and asks.

If the coding turns out right, ask about a payment plan, which I have never seen advertised and have seen given more than once.

How it ended

Tuesday, she called. The sick visit was correct, the lab was the mistake, an out-of-network one, and after two calls the bill came down to $180, which is not nothing, and is not $400 either.

Then she booked the next yearly visit. And this time, she says, the cough gets its own appointment.

Insurance letters, school letters, clinic letters, all of it lands in English, and the Russian at home gets thinner in the same year. Palme School teaches children from four years old, online, in small groups, 40 minutes a lesson, and every family starts with two free sessions, a conversation with a methodologist and then a trial lesson in a group. A child who follows Russian and answers back in English belongs in Russian for bilingual children. When the speech is fine and the page is where everything stops, that is the reading school.

Frequently asked questions

Is the yearly children's check-up free?

On plans that follow the Affordable Care Act, the preventive part of a well-child visit is covered with no copay or deductible when the provider is in network. Plans that are exempt from the ACA, such as older grandfathered plans and some government and self-insured plans, are not required to cover it that way.

Why did we get a bill after a visit we were told was covered?

Common reasons include a separate problem handled during the same visit and billed as a sick visit, services outside the preventive list for that age, services done more often than the schedule expects, a code the insurer did not accept, or a plan that is not ACA-compliant.

How many well-child visits does a child need?

Pediatric guidance sets about 11 visits before age two and a half, then one visit a year from age 3 through age 21.

What does Medi-Cal cover for children?

For children and teens under 21, Medi-Cal covers check-ups, screenings and preventive care, and federal rules require coverage of medically necessary services for children. Eligibility depends on income and household size.

What should we do about an unexpected bill?

Call the billing office first, ask for an itemized bill, and ask which services were billed as preventive and which were not. Practices review their own records for errors, and if the coding turns out to be correct, ask about a payment plan.

Palme School: Russian for bilingual children · Reading school · Free materials for families

Monica Perez is from Rosario, Argentina. These days she does nails in Los Angeles, and her regulars are mostly Russian-speaking, which is how these stories reach her before they reach anybody else.