Preventive care vs. diagnostic care

Sometimes, the exact same test or screening is 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.

How Priority Health pays for preventive care services

It depends on the plan you have.

Most Priority Health plans

Priority Health pays the cost in full for preventive services whether you have met your deductible or not.

Grandfathered Priority Health plans

If your plan is "grandfathered" under the Affordable Care Act, you'll pay a copayment for preventive health care services, but that copayment doesn't count against your deductible. Also, if your plan includes prescription drugs, then the drugs listed in the Preventive Health Care Guidelines aren't included as benefits in your Priority Health plan. See your coverage documents for details.

Short-term MyPriority plans

You'll have to pay for preventive care services.

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.

  • You will have to pay for a health care service intended to diagnose or determine the type or cause of your symptoms for up to the amount of your deductible before health plan begins to pay for it. This is called "meeting" your deductible. Your deductible is the amount you pay each year before your health plan starts to pay for medical services listed as benefits in your plan.
  • You may also have to pay coinsurance after you meet your deductible. Coinsurance is your portion of the cost for medical services listed as benefits in your insurance plan documents or prescriptions listed in the approved drug list.
  • 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.