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 tore my ACL. I went to my PCP and she ordered an MRI.”

Since the office visit and the MRI are both diagnostic, you will have out-of-pocket costs.

Depending on the plan that you are enrolled in, you may be responsible for a co-payment/ deductible and/or coinsurance.

Preventive and Diagnostic

“I went to see my PCP for my annual, routine check-up. At the time of the appointment I had a sore throat. I asked my PCP to assess whether I was symptomatic of strep throat.”

Since the routine office visit is preventive you pay nothing for the check-up; however, your PCP may bill part of the visit as diagnostic. When this happens, you will have an out-of-pocket cost  

For more details view your plan summary and description.