Explain How A Service Can Go From Preventive To Diagnostic

The Affordable Care Act (ACA) mandates that all qualified health insurance plans (except grandfathered plans purchased prior to March 23, 2010 and still in place) include coverage for ten essential health benefits. That does non mean these medical services are necessarily gratis, merely that your health insurance will cover some or all of the cost.

But certain preventive services are costless. This means your health insurance must cover 100% of the service without charging yous a co-payment or co-insurance, even if you lot have not even so met your deductible .

NOTE: you must use an in-network provider to receive free preventive care.

Preventive Services vs. Diagnostic Services

Many people are surprised to learn a service they believed to be preventive — and therefore gratuitous — was not considered preventive by the insurance company — and therefore resulted in a medical merits.

It is of import to understand the departure between a preventive service and a diagnostic service.

Preventive services are things that forbid health problems. Preventive intendance happens earlier yous feel ill . Examples are immunizations, lab tests, physical exams, certain medications.

Diagnostic services are things that help your doctor understand the symptoms y'all're having and diagnose an illness. Diagnostic intendance happens when you feel sick or have a known health issue.

The tricky part is sometimes the aforementioned service may be preventive — and free — under certain circumstances, yet diagnostic — and not gratis — under others.

How Do I Know if the Care I Receive is Preventive or Diagnostic?

Whether a service is preventive or diagnostic depends on the reason for having it.

In full general, a medical service is considered diagnostic if it is done for the purpose of monitoring, diagnosing, or treating a known health outcome or symptom. For example:

If you have a known, already-diagnosed chronic affliction like diabetes, and your dr. monitors your status with certain tests, these tests are considered diagnostic.

If a preventive screening test reveals a wellness problem and then your medico orders more tests to farther diagnose the exact issue, these tests are considered diagnostic.

If you are having symptoms, like abdominal hurting, and your doc orders tests to figure out the cause, these tests are diagnostic.

A service is considered preventive if it is done for screening purposes, and not based on any symptoms. Sure preventive services, when done on a recommended schedule (e.one thousand., at a certain age or frequency), are covered at 100%.

The Same Service can be Preventive or Diagnostic, Depending on the Reason

Hither are a few examples of services that can be either preventive or diagnostic, depending on the reason for the service:

Mammogram – preventive if washed as a screening based on your age or family unit history; diagnostic if yous have symptoms like pain or accept detected a lump.
Cholesterol testing – preventive if done every bit a screening based on your age or family history; diagnostic if you were already diagnosed with high cholesterol and your doctor is monitoring your numbers.
Colonoscopy – preventive if washed as a screening based on your age or family history; diagnostic if you have symptoms similar bleeding or irregularity.
Colon Polyp Removal – the removal itself is preventive if washed as part of a screening colonoscopy; if sent to the lab for testing, this is diagnostic.

Understand Your Policy

It is all-time to fully understand the provisions of your health insurance policy when seeking medical care. You tin can consult your plan's documentation for specifics on your coverage. If we helped you lot enroll in coverage, yous can also give us a call and nosotros'll be glad to help!