Preventive vs. Diagnostic Medical Services Under the Affordable Care Act

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 not mean these medical services are necessarily free, merely that your health insurance will cover some or all of the cost.

But certain preventive services are free.  This means your health insurance must cover 100% of the service without charging you a co-payment or co-insurance, even if you have not yet 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 free — was not considered preventive by the insurance company — and therefore resulted in a medical claim.

It is important to understand the difference between a preventive service and a diagnostic service.

Preventive services are things that prevent health problems.  Preventive care happens before you feel sick.  Examples are immunizations, lab tests, physical exams, certain medications.

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

The tricky part is sometimes the same service may be preventive — and free — under certain circumstances, yet diagnostic — and not free — 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 general, a medical service is considered diagnostic if it is done for the purpose of monitoring, diagnosing, or treating a known health issue or symptom.  For example:

If you have a known, already-diagnosed chronic disease like diabetes, and your doctor monitors your condition with certain tests, these tests are considered diagnostic.

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

If you are having symptoms, like abdominal pain, and your doctor 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.  Certain preventive services, when done on a recommended schedule (e.g., at a certain age or frequency), are covered at 100%.

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

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

• Mammogram – preventive if done as a screening based on your age or family history; diagnostic if you have symptoms like pain or have detected a lump.
• Cholesterol testing – preventive if done as 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 done as a screening based on your age or family history; diagnostic if you have symptoms like bleeding or irregularity.
• Colon Polyp Removal – the removal itself is preventive if done as part of a screening colonoscopy; if sent to the lab for testing, this is diagnostic.

Understand Your Policy

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