Seeing your provider for regular checkups and exams is an important part of staying healthy. Under health care reform, many preventive care services and screenings are covered at no cost to you when you visit a doctor in your health insurance network. Diagnostic services, on the other hand, may be subject to your plan’s deductible, copayment or coinsurance, and will usually apply to your annual out-of-pocket maximum.
Preventive Services Keep You Healthy
No-cost preventive services such as routine screening tests, immunizations, well-woman visits and children’s well-check exams are intended to maintain your health and identify potential health issues before they become serious. During your preventive care visit your doctor will determine which tests or screenings may be beneficial based on your age, gender, general health and family health history.
Diagnostic Services Diagnose, Treat or Manage Health Conditions
Diagnostic services are intended to treat ongoing or already identified health conditions or issues. For example, lab services may be ordered due to current symptoms that require further diagnosis, or to clarify previous abnormal test results.
Examples of When Services May be Billed as Diagnostic
If you visit your physician for a routine physical exam (preventive) but mention during the appointment that you have been experiencing abdominal pain, your appointment and resulting services may be billed as diagnostic and applied to your deductible, increasing your percentage of the cost.
If you receive a screening test that is sometimes covered as a preventive benefit, such as a colonoscopy, but your physician ordered it because of ongoing symptoms you have experienced, it may be billed as diagnostic.
Although health insurance carriers use the same guidelines for preventive care coverage, they may be explained differently in your benefits summary. See below for examples of preventive care guidelines.
Anthem Blue Cross Guide to Preventive Care
Blue Shield Guide to Preventive Care