When you go to the doctor for a preventive visit, it is often covered without a copay. But if the office charges you, you may not understand why you’re being charged. Many times, it’s because your visit went from preventive to diagnostic. We’ll get into more details, but one way to tell the difference between the two is to ask yourself:
- Do I feel sick or have symptoms? This is likely diagnostic.
- Am I feeling OK and need to go to the doctor only for my annual check-up? This is preventive.
To help you make well-informed decisions about your health care and give you a better understanding of preventive and diagnostic care, let’s start with what these terms mean.
What is preventive care?
Preventive care is designed to keep you healthy, and it’s usually included as a covered benefit with your plan. It’s meant to help prevent illness or detect problems before you notice any symptoms.
What is diagnostic care?
Diagnostic care involves treating or diagnosing a problem you’re having by monitoring existing problems, checking out new symptoms and following up on test results that may not have been in the normal range. Diagnostic care includes services for the routine care of a chronic condition or existing health problem.
How do the differences affect my coverage?
Your insurance coverage may be different depending on which type of services you receive. That’s why it’s important to know what type of service you’re getting. Be sure to check your plan documents to find out whether the services your doctor recommends are included in your coverage.
If your doctor or other health care professional recommends any tests, be sure to ask why.
“Insurance coverage depends on why the test is being done, as the coverage for the service may change based on how the test is defined,” HAP registered nurse Ellen Martindale explains. “The same test or service can be either ‘preventive’ or ‘diagnostic’ – which includes tests or services for the regular care of a chronic health condition. Many preventive services are covered at 100 percent – meaning no out-of-pocket cost to you. In some cases, diagnostic care may mean you have some out-of-pocket costs such as copays, deductibles or coinsurance.”
- If a service is considered diagnostic or routine chronic care, your usual out-of-pocket costs (copay, coinsurance, deductibles, etc.) apply.
- If a diagnostic or routine chronic care service is performed during the same visit as a preventive service, you may have out-of-pocket costs.
Here are a few examples of common services and when they may be considered preventive or diagnostic:
| Office visit
||You go to your doctor for your annual wellness check-up.
||You go to the doctor for your annual check-up but you’re also treated for your ongoing cough.
||You have a visit for a routine mammogram or screening.
||Your doctor orders a mammogram to learn more about a lump that was found.
||You have no symptoms and go in for a routine colonoscopy.
||Your doctor orders a colonoscopy based on your symptoms.
| Blood test
||You have high blood pressure – a risk factor for diabetes – so your doctor does a routine diabetes blood check. The blood test is being used to see if you need any further tests.
||Your doctor orders a blood test because you have symptoms that may be caused by diabetes. The blood test is now being used as a tool to make the correct diagnosis as symptoms may mean different things.
It’s important to get all your required preventive services to help avoid health issues in the future. Think of it like getting oil changes. You change your oil regularly to get more life out of your vehicle.
If you take care of your health the same way, chances are you’ll get more life out of you.
To learn more, visit HAP Health & Wellness.
HAP members, you can check your out-of-pocket costs by logging into your hap.org account and then clicking on Benefits. You may also view our Preventive Service Guide by logging in and selecting Member Resources.
This blog post is not a replacement for your health care provider’s advice. It is only intended to be a general guideline. Be sure to talk to your doctor about screenings and exams you may need as a result of your health, family history and other factors. Refer to your benefit plan for detailed information on your coverage.