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When we’re feeling healthy, we may not think of going to the doctor or about what is covered under preventive care. But the funny thing about health insurance is, you usually get the most coverage when you’re well — and pay the most out-of-pocket when you’ve been diagnosed with a problem. Under the guidelines of the Affordable Care Act (ACA)1 and depending on your insurance plan, you may be able to take advantage of many preventive screenings through an in-network provider at no cost to you. But the requirements can get a little confusing, so it pays to understand which preventive care services are fully covered and under what circumstances a screening could result in out-of-pocket costs.
Preventive vs. diagnostic care
It all comes down to the difference between preventive care and diagnostic care. Preventive care is something you get when you’re healthy, to make sure you stay healthy. In most cases, if you aren’t experiencing any particular symptoms or problems, the tests or screenings your doctor orders will be considered preventive. But if a preventive screening shows something abnormal, your care can very quickly become diagnostic.
Is all preventive care covered at 100 percent?
Not necessarily. Check with your insurance company to learn what preventive care services can be provided to you at no cost. Most insurance companies do place limits on preventive care. For instance, you may only be able to receive full coverage for one well visit or particular screening per year. And in most cases, preventive care will only be fully covered if you go to an in-network provider. Check with your doctor and insurance company to learn what preventive care you’re eligible for.
What qualifies as preventive care?
Preventive care services vary depending on your age, gender, and medical history. Examples include:
- Well visits
- Standard immunizations
- Cancer screenings
- Certain types of bloodwork
Preventive care services for children may include2:
- Hearing and vision screenings
- Behavioral assessments
- Developmental screenings
- Autism screening between the ages of 18 and 24 months
- Alcohol and drug use assessments for teens
- Lead screenings for at-risk children
- Obesity screenings and counseling
What is diagnostic care?
Diagnostic care includes the doctor’s visits, tests and procedures needed to diagnose and monitor a medical condition. Diagnostic care is the type of care that kicks in when a preventive care screening turns up something that could require treatment. In this case your doctor will order more tests or screenings in order to diagnose the problem and determine proper treatment. Diagnostic care may include:
- X-rays or ultrasounds
The coverage for diagnostic care varies according to your particular health plan, but will usually require you to pay for some of the cost out-of-pocket.
When is preventive care not covered?
Provided you’re within your insurance company’s requirements in terms of screening frequency and network eligibility, most preventative care will be covered at 100 percent, at no cost to you.3But it can get confusing because a typical preventive care screening such as a mammogram may be considered diagnostic care if something is found during your routine exam. In this case, your doctor may order a follow-up mammogram which will then be considered a diagnostic screening. Another tricky one is a colonoscopy. A preventive colonoscopy is usually recommended after a certain age so check with your insurance company to see if you have coverage for a colonoscopy before 50, for example. And at any age, if a polyp is found and removed during a routine, preventive colonoscopy, some insurance companies will consider that colonoscopy to be diagnostic.4 So the rule generally is, if you haven’t been diagnosed with any problems, your tests or screenings are preventive. But if an issue is discovered, it might be considered diagnostic care and may involve out-of-pocket costs.
Do the research to know your costs
When you schedule a procedure, ask both your healthcare provider and insurance company what your costs will be. Sometimes the doctor’s billing department won’t be sure if something is covered or not — or won’t know until after they bill your insurance company. But in order to avoid a surprise bill, always do some digging to get the information yourself.
It’s also a good idea to make sure both your doctor’s office and insurance company are on the same page when it comes to billing. If the wrong code is submitted to insurance, it could result in a denial of coverage and a big bill. Always confirm your coverage and request that your doctor’s office bills for your care correctly.
Inquire and communicate
As a patient, you’re also a consumer. When shopping in a store you probably look at the price tag before you buy. You should also look into what a medical test will cost and learn what your coverage is. This way, you can avoid any surprise charges. If you receive a bill for something that’s supposed to be covered at 100 percent, don’t panic. Follow up with your doctor’s office to make sure they billed for the care correctly. In some cases, you may want to ask a representative from your insurance company to call your doctor’s office directly to sort things out. Even doctor’s offices make mistakes and they may have to resubmit a bill to the insurance company to get it right.
1 “Preventive Care,” U.S. Department of Health and Human Services. Retrieved from:
2“ACA Coverage of Children’s Preventive Care,” Elizabeth Davis, RN, 12/31/17. Retrieved from:
3Preventive health services, healthcare.gov. Retrieved from:
4“I Am Due For a Colonoscopy. Is it Covered?”, Ryan Kennelly, 5/9/19. Retrieved from:
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