Preventive versus diagnostic care

Preventive care includes services such as routine check-ups, screening tests, and immunizations for when you are symptom free and have no reason to believe that you might be sick.

Diagnostic care includes tests/procedures ordered by a physician and office visits needed to help diagnose or monitor your condition or disease. Diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services, and other tests.

Preventive and diagnostic care may occur during the same visit.
For example, during a routine check-up your doctor discusses a chronic illness you may have. The tests your doctor orders may be preventive (such as a screening mammogram) and other tests may be diagnostic (such as a cholesterol check for someone with high cholesterol).

Why you need to understand the difference
Understanding the difference between preventive and diagnostic care will help you anticipate when cost sharing applies to certain services.

In most cases, you do not pay for preventive care; however, cost sharing applies to diagnostic care. When both preventive and diagnostic care occurs during the same visit, you pay something for the diagnostic services (i.e., co-payment, deductible, and/or co-insurance).

EXAMPLES

TYPE OF COST SHARING

Preventive

“I just had my routine check-up with my PCP. My PCP ordered routine labs, such as CBC and cholesterol screening as part of my visit. I am not symptomatic and I am not being followed for a condition. ”

None
Diagnostic

“I was jogging last week and sprained my ankle. I went to my PCP and she ordered an x-ray to make sure nothing was broken.”

You pay a co-payment for the office visit. Since an x-ray is a diagnostic test, you are responsible for the cost of the test in the form of a deductible and/or co-insurance.*
Preventive and Diagnostic

“I was diagnosed with low iron levels. My PCP ordered some routine labs plus a lab to check my iron level as part of my routine check-up.”

You pay nothing for the check-up; but you are responsible for the cost of the lab test to monitor your iron levels in the form of a deductible and/or co-insurance.*

*Diagnostic tests are not subject to a deductible and co-insurance for union members. All services, except preventive care, are subject to deductible and co-insurance for High Deductible Health Plan members.