Preventive Care — What’s Covered and What’s Not

When we're feeling healthy, we may not think of going to the doctor, but doing so can be extremely beneficial. “Preventive care" - routine screenings, tests, and healthcare counseling - are meant to stop illnesses from happening or detect conditions early when treatment and management can help them from becoming more serious.

Preventive care is also effective at preventing or lessening the severity of illnesses and lessening the associated healthcare costs, so many insurers cover 100 percent of the cost of most preventive care. However, knowing which preventive care is covered and how to get the most coverage available can be tricky. It pays to understand which preventive care services are fully covered and under what circumstances a screening could result in out-of-pocket costs.

Preventive vs. Diagnostic Care

It all comes down to the difference between preventive care and diagnostic care. Preventive care is something you get when you're not experiencing any abnormal symptoms. For instance, at your annual physical, health care providers may order blood and urine tests, take your blood pressure, check your heart rate, screen for mental health conditions, give you vaccinations, etc. These are all preventive.

If a preventive test shows something abnormal, however, your care can very quickly become diagnostic. Diagnostic care is meant to find out what is wrong, and to help determine what to do about it.

Is All Preventive Care Covered at 100 Percent?

Under the guidelines of the Affordable Care Act (ACA) and depending on your insurance plan, you may be able to take advantage of many preventive screenings through an in-network provider at no cost to you. However, not all insurance plans cover preventive care.

Most insurance companies do place limits on preventive care. For instance, you may only be able to receive full coverage for one well visit or one of each type of screening per year. In some cases that may mean that you have to wait a full calendar year before you can get another similar preventive screening. For example, if you had your annual physical on March 31, 2022, your plan may not cover another annual physical before March 31, 2023. It is important to check with your insurance company to understand how they interpret once a year. In most cases, preventive care will only be fully covered if you go to an in-network provider. Check with your doctor and insurance company to learn what preventive care you're eligible for and the coverage levels.

What Qualifies as Preventive Care?

Preventive care services vary depending on your age, gender identification, and medical history. Examples include:

• Well visits, such as an annual physical
• Standard immunizations
• Cancer screenings, such as for breast or colon cancer
• Certain types of bloodwork
• Vaccinations
• Cholesterol screenings

Preventive care services for children may include:

• Hearing and vision screenings
• Behavioral assessments
• Developmental screenings
• Autism screening
• Lead screenings for at-risk children
• Obesity screenings and counseling
• Immunizations

What Is Diagnostic Care?

Diagnostic care includes visits to health care professionals and the tests and procedures needed to diagnose, monitor, and treat a medical condition. Diagnostic care may include:

• Biopsies
• X-rays or ultrasounds
• Endoscopy
• Echocardiograms

The coverage for diagnostic care varies according to your health plan. Sometimes you must pay for some of the cost out-of-pocket through a copayment or coinsurance, at least until a deductible is reached.

When Is Preventive Care Not Covered?

Provided you're within your insurance company's requirements in terms of screening frequency and network eligibility, most preventive care will be covered at 100 percent, at no cost to you.

Sometimes the same test can be either preventive or diagnostic. For instance, a blood sugar test can be preventive when it is part of a physical. But it can be diagnostic when a person is reporting symptoms of possible diabetes, such as extreme thirst, urinating often, blurry vision, or unexplained weight loss.

Similarly, a preventive mammogram may become diagnostic care if it is done because something was found during a routine exam. If your doctor orders a follow-up mammogram, it will be considered a diagnostic screening and subject to a copayment, coinsurance or deductible, as defined by your plan.

Another tricky one is a colonoscopy. A preventive colonoscopy is usually recommended after a certain age so check with your insurance company to see if you have coverage before you get a colonoscopy. If a polyp is found and removed during a routine, preventive colonoscopy, some insurance companies will consider that colonoscopy to be diagnostic.

In general, if you haven't been diagnosed with any problems, your tests or screenings are usually preventive. But if an issue is discovered, it might be considered diagnostic care and may involve out-of-pocket costs.

Do The Research to Know Your Costs

When you schedule a procedure, ask both your healthcare provider and insurance company what your costs will be. A provider's billing department may not be sure of the coverage level if something is found and the service becomes diagnostic, but they ought to be able to tell you what a preventive test or procedure will cost you if anything.

Oversee Billing

It is a good idea to make sure both your doctor's office and insurance company are on the same page when it comes to billing. You may want to ask your healthcare provider for the billing code they will use for the procedure and ask your insurer to check the associated costs. If your provider submits the wrong code to the insurance company, it could result in denial of coverage and a big bill. If this happens your provider should work with the insurer to correct the mistake or appeal the insurance company's decision.

Managing Healthcare Costs with CareCredit

If you are looking for an option to help manage your medical bills, consider healthcare financing with the CareCredit credit card. The CareCredit card can help you pay for the care you want and need and make payments easy to manage.* Apply today and use our Acceptance Locator to find a provider near you that accepts CareCredit. Continue your wellness journey by downloading the CareCredit Mobile App to manage your account, find a provider on the go, and easily access the Well U hub for more great articles, podcasts, and videos.

Our Expert Reviewer

Patty Caballero and her team of consultants together have more than 35 years of health insurance knowledge working for some of the biggest health insurance companies in the US. She has knowledge in building brands and strategic initiatives to help consumers better understand their health benefits.