Members often have questions about their health plan, from the definition of terms to how to best utilize their coverage. Our Term Talk series aims to answer commonly asked questions to help you better understand health insurance and empower you to make decisions about your coverage that best fits your needs.
A common dilemma:
Sometimes I go to appointments with my doctor and don’t have to pay for anything, yet in other instances—like when I broke my ankle—I had a copay and later received a bill for the X-ray. It’s confusing trying to figure out what services are covered through my health insurance and which ones I’ll be expected to pay for. Could you explain what is considered preventive care and what isn’t?
To start, let’s first define preventive care and diagnostic care:
Preventive care is the care you receive to prevent illnesses or diseases and consists of measures taken for disease prevention. It’s basically what’s done before you’re sick to continue staying healthy. Examples of preventive care include annual check-ups, immunizations and certain screenings.
Unlike preventive care, diagnostic care is care you receive when your doctor is testing or treating you for a symptom or health issue you already have, like an existing condition, illness or injury. Examples of diagnostic care may include a doctor’s visit for a minor health issue like a rash or virus, as well as diagnostic tests or screenings for a suspected or known medical condition. For instance, X-raying a sore ankle to confirm if it’s broken is considered diagnostic care since it was a test done for a symptom, rather than to prevent a future health issue.
To understand preventive care vs diagnostic care, it’s first important to look at why a certain health care service is suggested. If you get your cholesterol checked as part of a recommended screening, that initial screening would be preventive since it’s being done to help prevent high cholesterol. However, if you already take medicine for high cholesterol and get your cholesterol regularly checked by your doctor for that reason, this could be considered diagnostic since a test is being done because of an existing condition.
When is there member cost-sharing?
Preventive care and diagnostic care are different when it comes to cost sharing. Preventive care services under the Federal Health Care Reform Law are covered with no member cost-sharing, meaning the member won’t have to pay for the preventive care they receive. For a list of preventive services covered with no cost to members, please see the Preventive Services notice on our website.
On the other hand, if you receive diagnostic care, you may be responsible for some cost sharing, depending on your plan. The type of health plan you have may also be a factor in the amount a member is expected to pay.
You may also be responsible for some cost sharing if your preventive care reveals the need for diagnostic testing. For instance, at your annual check-up, you may use that time to discuss the ongoing back pain you’ve been experiencing. The check-up itself is covered under preventive care and won’t have a cost associated with it. However, if your doctor recommends a CT scan or other test to investigate the cause of back pain, that would be considered diagnostic care and could have a cost associated with it if you chose to have the scan done.
How to navigate preventive care vs. diagnostic care
Even with an understanding of preventive care and diagnostic care, it can still be confusing to navigate the difference when at an appointment or experiencing a health concern. In order to avoid any unexpected costs, it’s always best to contact your health insurer to confirm whether a recommended test or lab is going to cost you anything.
For Harvard Pilgrim members, you can also visit your secure portal account to learn more on how diagnostic care is covered under your specific health plan. And Harvard Pilgrim members can utilize tools like Reduce My Costs and Estimate My Cost to help determine what the member cost-share will be for a diagnostic health service.
