Preventive care and diagnostic medical care both play an important part in keeping you as healthy as possible. But, sometimes the difference between the two isn’t clear.

What is Preventive Care?

Preventive care includes immunizations, lab tests, screenings and other services intended to prevent illness or detect problems before you notice any symptoms. The right preventive care at the right time can help you stay well and could even save your life.

What is Diagnostic Medical Care?

Diagnostic medical care involves treating or diagnosing a problem you’re having by monitoring existing problems, checking out new symptoms or following up on abnormal test results.

Examples of diagnostic medical care include:

  • Colon cancer screening (colonoscopy) to evaluate rectal bleeding
  • Mammogram to follow up on a breast lump

Why Does It Matter If My Services are Preventive or Diagnostic?

Your insurance coverage may be different depending on which type of services you receive. Many preventive services are covered at 100 percent (at no out-of-pocket cost to you).

Be sure to ask your doctor why a test or service is ordered. The same test or service can be preventive, diagnostic or routine chronic care (regular care based on a chronic health condition) depending on why it’s done, and the cost for the service may change based on how it’s defined. Here are a few examples of how the same tests can be preventive, diagnostic or routine chronic care:

 Test/Service/Exam  Preventive  Diagnostic  Routine Chronic Care
 Blood Pressure Check  A person with no history of high blood pressure gets a routine blood pressure check to screen for high blood pressure.  A person with risk factors for high blood pressure, like being overweight and smoking, visits the doctor because he or she has early morning headaches.  A person with a history of high blood pressure gets a blood pressure check to be sure his or her medication is helping
 Mammogram  A 55-year-old woman gets getting a routine mammogram to screen for breast cancer.  A 55-year-old woman who noticed a lump in her breast gets a mammogram to evaluate the lump.  A 55-year-old woman who had a lump removed from her breast two years ago for cancer gets a follow-up mammogram.

If a service is considered diagnostic or routine chronic care, your usual copayment, coinsurance and deductibles apply. It’s important to know what type of service you’re getting. If a diagnostic or routine chronic service is performed during the same healthcare visit as a preventive service, you may have copayment and coinsurance charges. Refer to your benefit plan for detailed information on your coverage.

The recommendations in this article are not a replacement for your doctor’s advice. They are intended only as general guidelines for preventive care. Please consider the information presented here, but make sure to talk to your doctor about screenings and exams you may need now and on a regular basis, depending on your current health, family history and other individual factors. The Preventive Care Guidelines represent the minimum level of required coverage. Refer to your benefit plan for detailed information on your coverage.