It’s no secret that navigating health insurance information can be a challenge. One commonly asked question among insurance subscribers is why their plan covers some health care services at no cost, while other services require cost sharing.
When subscribers don’t fully understand the difference between these types of services, it can mean they get asked to pay when they aren’t expecting it.
To prevent this frustrating situation, it’s helpful to clearly recognize what types of services are covered by your health insurance plan and what the differences mean for your wallet. The answer often comes down to whether the services are preventive or diagnostic.
What are preventive and diagnostic services?
In the health insurance world, preventive is a term used to describe a very specific list of services. This list is defined by nationally established guidelines. Preventive services are certain annual visits, tests, and immunizations that prevent health problems. They’re done before you are diagnosed with a condition, while you’re healthy and show no symptoms. These services are covered at no cost to you when you see an in-network provider.
Any service covered by a plan that isn’t preventive is defined as a diagnostic service. Diagnostic services are what providers recommend if you have symptoms or risk factors for a certain disease or illness, or have a known medical condition or injury. Diagnostic services have cost sharing, meaning you'll pay some of the cost, and your insurance will cover its portion.
The line between preventive and diagnostic care can sometimes blur. Even though you might regularly see a doctor about your asthma, diabetes, or another health issue, those visits are all about monitoring a known condition. For those visits, you’d be required to pay cost sharing. But, if you haven’t been diagnosed and aren’t showing symptoms, the tests your doctor does to screen for certain conditions, like diabetes, would have no cost sharing.
Here’s where things can get a bit more confusing. When you visit your doctor for preventive care and they do other tests at the same time, you might have to pay. Why? Well, say you’re visiting the doctor for your annual physical exam. During that visit you share some symptoms you’ve been experiencing, and your doctor orders a specific lab test to learn more. While your plan covers the annual physical exam, that lab service and any follow-up visits don't always qualify as preventive, so cost sharing may apply.
Keep in mind that a doctor’s number one job is to look out for their patients’ health. That means recommending tests and treatments to help maintain good health, even when those recommendations aren’t necessarily covered at no cost to you.
Employees don’t need to navigate this alone
If you or your employees need more information on what costs they will incur for certain services, there are plenty of resources to help.
- They can refer to their health insurance plan documents for a list of covered services and any associated cost sharing.
- Their provider’s office staff can research how the claim was coded.
- An insurance company’s customer service staff can also provide answers.
- This article can be a helpful educational resource to share.
By being proactive in understanding your health insurance plan and coverage, you can avoid misunderstandings about the costs of services provided or ordered by your physician.