Paying for preventive vs. diagnostic care
Sometimes, the exact same test or screening can be covered by your plan in two different ways.
Preventive = Deductible does not apply
When you have no symptoms, no reason to think you aren't healthy, and you get a service or test listed in the Preventive Health Care Guidelines, it's a "preventive service." If your doctor orders a preventive service more often than these guidelines suggest, it's still a preventive service.
- Priority Health pays 100% for preventive services whether you have met your deductible or not.
- The exceptions are: If you're covered by a short-term (6 months or less) plan, or if your Priority Health plan is "grandfathered" under the Affordable Care Act (health care reform). See below to learn more.
Diagnostic = Deductible applies
When you have some risk factors or symptoms, your doctor may order one of the tests listed in the Preventive Health Care Guidelines as a "diagnostic service" to diagnose what's wrong. It's the same service, but it's not preventive care; see the examples below.
- You will have to pay for a diagnostic service up to the amount of your deductible before your Priority Health plan begins to pay for it. This is called "meeting" your deductible.
- You may also have to pay coinsurance after you meet your deductible.
- If you have a chronic disease and your doctor runs certain tests to monitor your condition, these are not considered preventive and will be subject to your deductible.
- If your doctor runs additional, non-routine tests to diagnose or confirm the diagnosis for a health condition during a preventive care exam, those tests are not considered preventive. Your deductible will apply.
- If you require follow-up visits or treatments for a condition found during a preventive exam, your deductible will apply to those visits or treatments.
- If your doctor recommends tests that are not proven to be medically necessary, your deductible will apply to the cost of these tests. Be sure to talk to your doctor to understand why he/she recommends these services.
How health care reform might affect what you pay
If you are in an employer group's health plan, you'll need to find out if the plan is "grandfathered." It means your employer has decided to keep the plan they were offering before the Affordable Care Act became law on March 23, 2010. Ask your employer or call our Customer Service department at the number on the back of your ID card.
If your plan is "grandfathered," your plan may have been set up so you pay a copay to get preventive health care. If your Priority Health plan is "grandfathered" and does not cover prescription drugs, then the drugs listed in these Preventive Health Care Guidelines aren't covered by your Priority Health plan.
If your Priority Health plan is not "grandfathered," the preventive health care services listed in our guidelines are covered at 100%. You don't pay anything.
Examples of preventive and non-preventive services
Before you have a test or service, it is good to understand if it will be covered as a preventive service in your plan. Remember - if the service is not preventive, your deductible, copays, and coinsurance may apply. The examples in the chart below may help.
||It's preventive when...
||It's diagnostic when...
|Colon cancer screening (colonoscopy or sigmoidoscopy)
||Your doctor wants to screen for signs of colorectal cancer based on your age or family history. If a polyp is found and removed during your preventive colonoscopy, the colonoscopy and polyp removal are preventive. If the polyp is sent for lab testing, the testing is considered diagnostic.
||You're having a health problem, like bleeding or irregularity. Or if the polyp you have removed is sent to a lab to be tested, the lab test is diagnostic.
||Your doctor does a mammogram based on your age or family history
||You're having a health problem, like pain, or you feel a lump. If you have a lump removed and sent to the lab for testing, this is also diagnostic.
||A blood glucose test is used to detect whether you have a problem with your blood sugar control, even though you may not have any symptoms
||You're diagnosed with diabetes, and your doctor checks your A1c
||Always diagnostic. Studies show that a metabolic panel isn't the best test for detecting or preventing illnesses
||Your doctor recommends a bone density test to screen for early signs of osteoporosis based on your age or family history
||You're having a health problem, or your doctor wants to determine the success of a treatment
|Prostate exam (PSA)
||Always diagnostic. National guidelines have changed recently because this test gives many false results.
||Always diagnostic. New national guidelines say there's no need for this test unless you have symptoms.