Preventive vs. diagnostic care

The Affordable Care Act (opens in new tab) requires health plans in the individual market to cover many preventive tests, screening exams, and services for free. But here’s something important to know.

If you have certain symptoms or a particular health history, a test that might otherwise be preventive may be considered diagnostic. When a test is part of diagnosing a condition, the test is covered subject to the cost-sharing (opens in new tab) structure of your plan, which means you may have to pay all or part of the bill.

Here’s a quick example: Say you’re a woman at your annual visit and your doctor recommends a mammogram because he or she thinks you might need to be screened, even though you don’t have any symptoms. That service would typically be considered preventive care and would be covered-in-full (opens in new tab). If, however, you or your doctor has noticed a symptom like a lump and think something’s wrong, then the service is diagnostic and subject to the cost-sharing of your plan.

A good rule of thumb is that if your physician determines that the test is medically necessary (opens in new tab) (and codes it as such on your bill), it will no longer be free, but will instead be subject to the same cost-sharing as other services on your plan.