Preventive care benefits can play an important role in maintaining your long-term health and keeping the cost of healthcare down. However, the difference between what is considered a preventive service and a diagnostic service isn’t always obvious.
One of the biggest differences between preventive and diagnostic services relates to the costs incurred by the member. Since the passing of the Patient Protection and Affordable Care Act, preventive services are covered at 100 percent, while diagnostic services are subject to cost-sharing (copayments, coinsurance or deductibles) and usually require individuals to pay for a portion of the service.
How to determine the difference
Preventive care refers to services that can help you stay healthy and identify problems early. These services are called preventive because they can help “prevent” serious health problems. Diagnostic services start when you already have signs of a health problem; therefore, your doctor may order tests to further diagnose your condition. As simple as this might sound, sometimes determining the difference gets a little confusing since there are a number of services, including mammograms and pap smears, which fall into both categories. For example:
A member goes to her doctor, and they remind her that she has reached the recommended age for annual mammograms. The member doesn’t have any concerns with her breasts but receives a mammogram for screening purposes only. In this case the mammogram would be considered a preventive service and would be covered at 100 percent.
A member goes to see her physician with a lump in her breast. The doctor recommends that she receive a mammogram to further examine the lump and determine if anything is wrong with her breast. In this case the mammogram would be considered a diagnostic service and would be subject to cost sharing.
If you have any questions regarding a certain procedure, be sure to check with your doctor or your health plan to determine whether it is considered a preventive or diagnostic service. They can help you make educated decisions about your health and healthcare services.