Preventive vs diagnostic care

The same test can be free or billed to you, depending on why it was done. This is what decides it.

What decides which one you get

The service does not change. The reason for it does. Your doctor puts a reason on the claim, and that reason decides which of the two your plan pays as. A mammogram on your birthday with no symptoms is preventive. The same mammogram to look at a lump is diagnostic.

Covered in full in network

• Annual physical or wellness visitOne routine checkup a year with no symptoms to discuss.
• Blood pressure, cholesterol, and diabetes screeningRoutine checks when you have no diagnosis and no symptoms.
• MammogramRoutine breast cancer screening at the interval your age calls for.
• ColonoscopyRoutine colorectal cancer screening, including the prep and the anesthesia.
• Cervical cancer screening (Pap test)Routine Pap test, usually done at a well-woman visit.
• Well-woman visitThe yearly OB-GYN checkup, including the screenings that belong to it.
• Prenatal screenings and counselingThe screenings, counseling, and vaccines that come with a healthy pregnancy.
• Well-baby and well-child visitsThe regular checkups a child gets on the standard schedule.
• Routine vaccinationsFlu shots and the standard vaccines for children and adults.
• Depression and behavioral health screeningThe short screening questionnaire, not a therapy visit.
• Counseling to quit smoking, drink less, eat better, or lose weightCounseling on the standard preventive list.
• Routine dental cleaning and examCovered by the dental plan rather than the medical plan, usually twice a year.

Billed at your normal share

• A visit about a symptomAnything you booked because something hurts, changed, or worries you.
• Lab work for a condition you already haveBloodwork to track diabetes, thyroid, or cholesterol you are being treated for.
• A repeat test after a screening found somethingA diagnostic mammogram or a follow-up colonoscopy after an abnormal result.
• Imaging for an injury or painAn X-ray, MRI, CT, or ultrasound ordered to find out what is wrong.
• An EKG for symptomsOrdered because of chest pain, palpitations, or dizziness.
• Tests to check how treatment is workingAny test repeated to see whether a medicine or therapy is doing its job.

Why you can still get a bill

• The provider was out of network

  Preventive care is free only when you use a provider in your plan's network. Out of network, the plan can charge you, and some plans cover nothing at all.

• The visit was about something else too

  If you bring up a new problem at your annual physical, the plan can pay for the physical in full and still bill you for the part of the visit that dealt with the problem.

• Something was found and dealt with

  If a screening turns into treatment in the same appointment, like removing a polyp during a screening colonoscopy, that part can be billed as diagnostic.

• The plan is grandfathered

  A small number of older plans predate the Affordable Care Act and do not have to cover the free preventive list. Your plan documents say if yours is one.

If a bill looks wrong, ask Sage. It can read the reason on your claim and tell you whether it was billed as preventive or diagnostic. Ask Sage