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Paying for preventative vs. diagnostic care

Preventative vs. Diagnostic Care

With the Affordable Care Act being on everyone’s radar this month, there’s a lot of discussion as to what’s preventative care and what’s diagnostic. Before you have a test or service, it is good to understand if it will be covered as a preventive service in your plan. Remember – if the service is not preventive, your deductible, copays, and coinsurance may apply.

Preventive = Deductible does not apply

When you have no symptoms, no reason to think you aren’t healthy and you get a service or test listed in the Preventive Health Care Guidelines, it’s a “preventive service.” If your doctor orders a preventive service more often than these guidelines suggest, it’s still a preventive service.

Diagnostic = Deductible applies

When you have some risk factors or symptoms, your doctor may order one of the tests listed in the Preventive Health Care Guidelines as a “diagnostic service” to diagnose what’s wrong. It’s the same service, but it’s not preventive care; see the examples below:

  • You will have to pay for a diagnostic service up to the amount of your deductible before your Priority Health plan begins to pay for it. This is called “meeting” your deductible.
  • You may also have to pay coinsurance after you meet your deductible.
  • If you have a chronic disease and your doctor runs certain tests to monitor your condition, these are not considered preventive and will be subject to your deductible.
  • If your doctor runs additional, non-routine tests to diagnose or confirm the diagnosis for a health condition during a preventive care exam, those tests are not considered preventive. Your deductible will apply.
  • If you require follow-up visits or treatments for a condition found during a preventive exam, your deductible will apply to those visits or treatments.
  • If your doctor recommends tests that are not proven to be medically necessary, your deductible will apply to the cost of these tests. Be sure to talk to your doctor to understand why he/she recommends these services.

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