Coverage of Children's Preventive Care

What's Free and What's Not

Child listening to his pediatrician's chest with a stethoscope
Image © Vicky Kasala/Getty Images

Thanks to the Affordable Care Act, health insurers in the U.S. have to cover preventive health care for both adults and children without requiring you to pay a deductible, copayment, or coinsurance.

However, what counts as preventive care can be confusing. Here’s an age-based list of preventive care services for children that, if recommended by your child’s physician, should be paid for by your child's health insurance free of cost-sharing.

Adults have a different list.

Children’s Preventive Care Covered Without Cost-Sharing

Newborns

  • Hearing Screening
  • Gonorrhea prevention medicine in the eyes
  • Sickle cell or hemoglobinopathy screening
  • Hypothyroidism screening
  • Phenylketonuria (PKU) screening

Age 0-11 months

  • Behavioral assessment
  • Blood pressure screening
  • Height, weight, and body mass index measurements
  • Medical History
  • Oral health risk assessment
  • Tuberculin testing if your child is at increased risk of tuberculosis
  • Developmental screening
  • Iron supplements for children ages 6 months to 12 months if at risk for anemia

Age 1-4 years

  • A behavioral assessment
  • A blood pressure screening
  • A height, weight, and body mass index measurement
  • A medical history
  • An oral health risk assessment
  • A tuberculin testing if your child is at increased risk of tuberculosis
  • A dyslipidemia screening if your child is at increased risk of a lipid disorder
  • Autism screening at ages 18 months and 24 months
  • Developmental screening for children under 3 years old

Age 5-10 years

  • A behavioral assessment
  • A blood pressure screening
  • A dyslipidemia screening if your child is at increased risk of a lipid disorder
  • A height, weight, and body mass index measurement
  • A medical history
  • An oral health risk assessment
  • A tuberculin testing if your child is at increased risk of tuberculosis

    Age 11-14 years

    • A behavioral assessment
    • A blood pressure screening
    • A dyslipidemia screening if your child is at increased risk of a lipid disorder
    • A height, weight, and body mass index measurement
    • A medical history
    • A tuberculin testing if your child is at increased risk of tuberculosis

    Age 15-17 years

    • A behavioral assessment
    • A blood pressure screening
    • A dyslipidemia screening if your child is at increased risk of a lipid disorder
    • A height, weight, and body mass index measurement
    • A medical history
    • A tuberculin testing if your child is at increased risk of tuberculosis

    Adolescents

    • Alcohol and drug use assessments
    • Cervical dysplasia screening for sexually active females
    • Depression screening
    • HIV screening if at increased risk
    • Sexually transmitted infection screening and prevention counseling if at increased risk

    All ages from birth to 18 years, or not age-specific

    • Fluoride supplements for children without fluoride in their water source
    • Hematocrit or hemoglobin screening
    • Lead screening for children at risk of exposure
    • Obesity screening and counseling
    • Vision screening
    • Immunizations as recommended based on age and population
      • Diptheria, tetanus, pertussis
      • Haemophilus influenzae type b
      • Hepatitis A
      • Hepatitis B
      • Human Papillomavirus
      • Inactivated Poliovirus
      • Influenza
      • Measles
      • Meningococcal
      • Pneumococcal
      • Rotavirus
      • Varicella

    What Preventive Care Isn’t Free

    If your child has a managed care health plan that uses a provider network, it’s allowed to charge cost-sharing for preventive care provided by out-of-network providers. If you don’t want to pay for your child’s preventive care, use an in-network provider.

    If a preventive service isn’t recommended by your child’s physician and:

    then it generally won’t be offered without cost-sharing.

    If your child’s health insurance is a grandfathered health plan, it’s allowed to charge cost-sharing for preventive care. The health plan literature will tell you if the health plan is grandfathered. Alternatively, you can call the customer service number on your child’s health insurance ID card or check with your employee benefits department if your child’s health coverage is through your job.

    Preventive Care Isn’t Really Free

    Although your child’s health insurance must pay for preventive health services without charging a deductible, copay, or coinsurance, this doesn’t mean those services are free. The insurer takes the cost of preventive care services into account when it sets premium rates each year.

    Although you don’t pay cost-sharing charges when your child receives preventive care, the cost of those services is wrapped into the cost of the health insurance. This means, whether or not your child gets the recommended preventive care, you’re paying for it anyway through the cost of the health insurance premiums.

    Sources:

    Preventive Health Services for Children, HealthCare.gov. Accessed 5/27/2015.

    Affordable Care Act Implementation FAQs - Set 12, The Center for Consumer Information & Insurance Oversight, Centers for Medicare & Medicaid Services. Accessed 5/27/2015.

    Affordable Care Act Implementation FAQs - Set 18, The Center for Consumer Information & Insurance Oversight, Centers for Medicare & Medicaid Services. Accessed 5/27/2015.

    FAQs about Affordable Care Act Implementation (Part XXVI), Employee Benefits Security Administration, United States Department of Labor. Accessed 5/28/2015.

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