Usually, yes. A medical dermatology visit for a child, such as for eczema, acne, warts or a rash, is generally covered when the dermatologist participates in your child's insurance plan. What you pay depends on the plan's specialist copay, deductible and coinsurance, and some plans require a referral from your child's pediatrician first. Cosmetic treatments are not covered by insurance.
The details depend on the kind of coverage your child has. Here is how the common types work in New York, and what to check before you book.
Children on a parent's employer or marketplace plan
If your child is covered as a dependent on your plan, the visit follows your plan's rules for specialist care. HealthCare.gov notes that you can add or keep children on your health plan until they turn 26.
Seeing a dermatologist in your plan's network usually costs less. Out-of-network care may cost more or may not be covered at all, depending on the plan.
Three terms decide what you pay. Here they are in plain words, based on HealthCare.gov's definitions:
- Copay. A fixed amount you pay for a covered visit. Many plans set a different copay for specialist visits, such as dermatology, than for primary care. Some plans charge only the copay even before you've met your deductible; others don't.
- Deductible. What you pay for covered care in a plan year before the plan starts to pay its share. Family plans often have both an individual and a family deductible, so your child's visit may count toward one or both.
- Coinsurance. Your share of the cost of a covered service, as a percentage, after you've met your deductible.
Your plan's Summary of Benefits and Coverage lists your numbers. Look for the row labeled "specialist visit."
Medicaid managed care and Child Health Plus in New York
New York has two public programs that cover many children:
- Medicaid covers eligible children and families. Many New York Medicaid members get their care through a Medicaid managed care plan, a health plan that contracts with the state and has its own network of doctors.
- Child Health Plus is New York's program for children under 19 who live in the state, aren't eligible for Medicaid and don't have other health insurance. Depending on family income, it is free or has a monthly premium. The New York State Department of Health says there are no copayments for services under Child Health Plus. Coverage comes through approved health plans in your county.
You can apply for either program through NY State of Health, the state's official health plan marketplace.
Because each plan has its own network, a dermatologist may participate in one Medicaid or Child Health Plus plan and not another. To check whether a specific dermatologist is in your child's network:
- Search the plan's online provider directory for the dermatologist or practice by name.
- Call member services at the number on your child's insurance card and ask whether that dermatologist is in network for your child's plan.
- Call the dermatology office with the plan name and your child's member ID.
Directories aren't always up to date, so it's worth confirming with both the plan and the office. To ask whether Bay Ridge Dermatology participates in your child's Medicaid or Child Health Plus plan, call (347) 497-4984 with the plan name and member ID ready.
Does your child's plan need a referral from the pediatrician?
It depends on the plan. HealthCare.gov explains that HMO and point-of-service (POS) plans usually ask you to get a referral from a primary care doctor before seeing a specialist, while PPO plans generally don't.
New York's model member handbook for Medicaid managed care plans describes specialist care the same way: the child's primary care provider refers them to a specialist, usually one in the plan's network. For ongoing care, such as long-term eczema treatment, the handbook also describes a standing referral that covers a set number of visits or a set length of time.
To find out what applies to your child:
- Check the plan type on the insurance card or in the plan documents.
- Ask member services whether dermatology needs a referral, and whether it has to be in place before the appointment.
- If one is needed, ask the pediatrician's office to send it ahead of time. Without a required referral, the plan may not pay for the visit.
Medical care is covered; cosmetic treatment is not
In general, insurance pays for care that diagnoses or treats a health condition. Bay Ridge Dermatology's medical dermatology care covers conditions such as acne, eczema, warts, rashes, skin infections, and hair and nail disorders, all of which can affect children.
Cosmetic treatments, done only to change how skin looks, are not covered by insurance. For example, removing a harmless skin tag or mole just because you don't like how it looks would be cosmetic, while checking a mole that has changed is medical. If one visit includes both a medical concern and a cosmetic question, ask how each part will be billed. Our post on medical vs. cosmetic dermatology explains the difference in more detail.
Plans Bay Ridge Dermatology accepts
Bay Ridge Dermatology, at 515 84th Street in Bay Ridge, Brooklyn, sees patients of all ages, pediatric through geriatric, so children are welcome. Most insurances are accepted, including Aetna, BCBS, Cigna, United, Medicare, Oxford, Empire and Humana.
Each insurance company offers many plans, and coverage can differ by plan and by service. Before the visit, confirm your child's specific plan, using the plan name printed on the card. The practice's insurance page has more details, and the new patients page covers forms and what to expect.
What to ask before the visit
Ask your insurer:
- Is this dermatologist in network for my child's plan?
- Does my child need a referral, and does it need to be on file before the visit?
- What is our specialist copay, and does it apply before the deductible?
- How much of our deductible have we met this year, and what is our coinsurance after that?
Ask the dermatology office:
- Do you accept my child's specific plan?
- If my child needs a procedure, such as wart treatment or a biopsy, is it billed separately from the visit?
- Could a lab bill us separately for any test?
- What should we bring? Usually that means the insurance card, a referral if one is required, and a list of the medicines and treatments your child has tried.
If you're paying without insurance, ask for a Good Faith Estimate. Under the federal No Surprises Act, providers must give patients who aren't using insurance an estimate of expected charges when they schedule care at least three business days ahead or when they ask, according to the Centers for Medicare & Medicaid Services.
Questions about coverage are easier to sort out before the appointment than after it. When you're ready, book online or call (347) 497-4984.
This article is general information, not medical advice. For advice about your own skin, see a dermatologist.