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Family Life

How Primary Care is Covered

Managed care plans usually pay for primary and preventive care visits, including:

Many managed care plans require families to pay a share of their primary care services, such as $5 to $20 for each visit to the doctor.

High Deductible Plans

Under high deductible plans, you may be responsible for payment until the deductible has been met, unless your plan was purchased after March 10, 2010. All high deductible plans purchased after March 10, 2010 must include 100% coverage for preventive services even if the deductible has not been met.

  • Know the extent that your plan covers preventive and primary care and remember to bring your insurance card with you to each visit. Ideally, the health plan should provide coverage for all recommended pediatric preventive care.
  • See the current AAP Recommendations for Pediatric Preventive Care Services for more information.

Your State's Health Insurance Marketplace

If you purchase health insurance through your state’s health insurance marketplace, (Enrollment begins October 1, 2013) most preventive services must be covered without copayment. However, there are significant variations in dental, vision, and rehabilitative services from state to state with marketplace insurance plans. Check your state for specifics.

How to Choose a Primary Care Doctor for Your Child 

It is recommended that you choose a pediatrician as your child's primary care doctor. A pediatrician has years of training and experience in children's health care.

  • If your pediatrician is not in the plan, you can ask the plan to include him or her. If you go to a pediatrician who is not in the plan, your plan may not fully pay or even partially pay for your care.
  • Ask your pediatrician which plans he or she is in and try to join one of those plans.
  • Before choosing a plan, you also should think about the hospitals your pediatrician is able to admit patients to and the pediatric specialists he refers patients to.
  • If you do not have a pediatrician, you may search the "Find a Pediatrician" tool on HealthyChildren.org or you can ask your managed care plan for a current list of pediatricians near you whose practices are open to new patients.

The Pediatrician's Role in Managed Care

A pediatrician provides primary care for newborns, infants, children, adolescents and young adults through age 21. As a primary care doctor, he provides preventive care, takes care of illnesses and injuries, and diagnoses and treats acute and chronic disorders.

A pediatrician makes referrals to pediatric specialists when needed and coordinates other services for the total care of your child. Your plan may require that your pediatrician serve as a "gatekeeper" to authorize or approve certain services. Without these approvals, you may have to pay for part or all of these services yourself.

If You Want to Change Doctors...

Finding a pediatrician who meets your family's needs is important. It is also best to stay with that pediatrician once you have made your choice. However, situations change and you may need to choose a new pediatrician.

All plans allow you to choose another doctor from those participating in the plan. Check with your plan to get information on how to do this. You must let your plan know if you change your pediatrician. Some plans only allow you to change doctors during a specific period of time.

 

Last Updated
10/3/2013
Source
American Academy of Pediatrics (Copyright © 2013)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.