Understanding Your Bill: Well-Child Visits and Additional Charges

What is a well-child visit?

A well-child visit (also called a "checkup" or "wellness visit") is a routine preventive care appointment. During this visit, your child's doctor will:

  • Check your child's growth and development
  • Perform a physical exam
  • Give recommended vaccines
  • Provide age-appropriate screenings (such as vision, hearing, or developmental screenings)
  • Discuss healthy habits, safety, and nutrition

Under the Affordable Care Act (ACA), these preventive services are covered by most health insurance plans with no copay, no coinsurance, and no deductible. This means you should not owe anything out of pocket for the preventive portion of the visit.

So why might I receive a bill?

Sometimes during a well-child visit, your child's doctor may need to address a medical concern that goes beyond routine preventive care. For example:

  • Your child has an ear infection, rash, sore throat, or other illness
  • You bring up a new concern such as headaches, stomach pain, or a behavioral issue
  • Your child needs a test or procedure to evaluate a specific symptom (such as a strep test or X-ray)
  • A prescription medication is needed to treat a condition found during the visit

When this happens, the doctor is providing two types of care in one visit:

  1. Preventive care — the routine well-child checkup (covered at no cost to you)
  2. Problem-based care — the evaluation and/or treatment of a specific medical issue (subject to your plan's normal cost-sharing)

Your insurance company requires that these two types of care be billed separately. The problem-based portion of the visit may result in a copay, coinsurance, or be applied to your deductible, depending on your specific insurance plan.---

Is this allowed under the law?

Yes. The Affordable Care Act requires insurance plans to cover recommended preventive services without cost-sharing. However, the law does not require free coverage for the diagnosis or treatment of medical problems — even if those problems are discovered or discussed during a preventive visit. The additional charge reflects the extra medical care your child received, not a charge for the well-child visit itself.

What can you do?

  • Ask questions at the visit. If you are unsure whether discussing a concern might result in an additional charge, ask your child's care team before the visit or at check-in.
  • Review your Explanation of Benefits (EOB). After the visit, your insurance company will send an EOB that shows what was billed, what was covered, and what you may owe.
  • Contact your insurance company. If you have questions about a charge, call the member services number on the back of your insurance card.
  • Talk to our billing office. Our staff is happy to help you understand your bill and can work with you on payment options if needed.---

A helpful way to think about it

Think of it like bringing your car in for a scheduled oil change (preventive maintenance — included in your service plan). While the mechanic is there, you mention a strange noise. Diagnosing and fixing that noise is a separate service with a separate charge. Similarly, your child's routine checkup is covered, but addressing an additional medical problem is a separate service.

We are here to help.

Our goal is to provide the best possible care for your child. We never want billing concerns to prevent you from raising important health issues during a visit. Please do not hesitate to bring up any concern about your child — we will always prioritize your child's health and will be transparent about any potential costs.

If you have questions about your bill, please contact our billing office at 617-361-1470.