If your family gets health insurance through an employer, this short window is usually your only chance all year to make changes. Before you choose, it’s worth taking an honest look at what you’re actually spending on your child’s care, and what you’re getting for it.
For many families, a concierge pediatrician with a flat annual fee and 24/7 access to your child’s doctor may be worth considering.
- What did your child’s everyday care cost last year?
Pull up last year’s statements and add up what you paid out of pocket for your child’s routine and sick care:
Sick visit copays or charges
Urgent care visits
In-office tests (strep, flu, COVID, urine)
Lab fees
Anything you paid toward your deductible for these visits
Then think about the time: waiting rooms, missed work, hours on hold trying to get an appointment.
For many families especially those on high-deductible plans, the total is bigger than they expect. - Are your child’s specialists and hospital in network?
Check any specialists your child sees and the hospital you’d want to go to. Networks change every year, so don’t assume last year’s answer still holds. - What’s the deductible, and how often do you hit it?
If your family rarely needs more than routine care, a higher deductible might save you money on premiums. If your child sees specialists or has a chronic condition, a lower deductible may cost less in the long run. - Are your child’s prescriptions covered?
Look up any regular medications on the plan’s formulary. Inhalers, allergy medications, and ADHD medications can vary a lot in cost from plan to plan. - Does the plan have out-of-network benefits?
If you see any doctors who don’t take insurance, this matters. PPO and POS plans usually include out-of-network coverage, while many HMO and EPO plans don’t. Even when a plan does, there’s often a separate, higher out-of-network deductible. Ask your benefits team for the out-of-network deductible and reimbursement rate for each plan. - Thinking about a high-deductible plan?
Lower premiums are appealing, but you’ll pay more out of pocket for specialists, imaging, and emergencies until you meet the deductible. Check whether the plan includes out-of-network benefits, and if you plan to open an HSA, ask your benefits
team or a tax advisor what those funds can cover. - What kind of care are you getting?
Cost is only half the picture. How quickly can your child be seen when they’re sick? Can you reach someone after hours? Does your doctor know your family? Those things matter, especially at 7 pm on a Tuesday with a feverish little one.
One predictable cost for everyday care Concierge Pediatrics doesn’t bill insurance, so it can help to think of us as an out-of-
network practice. One annual membership covers your child’s office visits, vaccines, and in-house labs, with no copays and no surprise bills. Members also get extended hours (8 am to 8 pm Monday through Thursday, and weekends till 1 PM) and more time with their doctor. We also provide a superbill you can submit to your insurance company for potential out-of network reimbursement, which may bring your cost down further depending on your plan.
You’ll still want insurance for everything outside our office, like specialists, hospital care, and emergencies. But once you’ve added up what everyday care cost you last year, you may find membership is more affordable than you thought.
Want help running the numbers? We’re happy to walk through it with you.
This article is for general information only and is not insurance, tax, or financial advice. Please review plan details with your employer’s benefits team.