Preventive vs. Diagnostic Care: What’s the Difference?

Understanding how healthcare services are classified helps you anticipate medical costs and avoid unexpected bills. Under your Sana plan, care is categorized as either Preventive or Diagnostic, which determines whether the service is covered at 100% or subject to plan cost-sharing.

Preventive Care (Covered at 100%)

Preventive care includes routine screenings, check-ups, and immunizations received when you are healthy and experiencing no symptoms.

• Your Out-of-Pocket Cost: $0 (Covered at 100% with no copay, deductible, or coinsurance required when using in-network providers).
• ACA Guidelines: To be covered at $0 out-of-pocket, the service or screening must be explicitly included on the official Affordable Care Act (ACA) preventive care mandate list.
• Key Condition: You must be symptom-free with no pre-existing symptoms related to the exam.
• Common Examples:
  • Annual routine wellness exams and well-child checkups (as defined by ACA guidelines).
  • Standard immunizations and vaccines (e.g., annual flu shot, tetanus).
  • Routine screening mammograms or colonoscopies for age-eligible members without symptoms.

Diagnostic Care (Subject to Cost-Sharing)

Diagnostic care includes tests, procedures, office visits, or follow-up care ordered to investigate specific symptoms, diagnose a new illness, or monitor an existing medical condition.

• Your Out-of-Pocket Cost: Subject to your plan's copay, deductible, or coinsurance.
• Key Condition: Triggered by symptoms, abnormal test results, or ongoing condition management.
• Common Examples:
  • Mammogram ordered to investigate a breast lump or breast pain.
  • Colonoscopy performed following a positive screening result or to monitor ongoing digestive symptoms.
  • Most blood work (e.g., lipid panels or thyroid tests)
  • X-rays or ultrasounds to evaluate an active injury or pain.

Quick Comparison

Important: How to Avoid Unexpected Diagnostic Bills

It is common for doctors to perform both preventive and diagnostic services during the same appointment. For example, if you discuss a new symptom during your annual exam, your doctor may order additional lab work or tests, which will be billed as diagnostic care.

Pro Tip for Your Visit: If you are adamant about receiving only a $0 cost-share preventive exam, you must explicitly discuss this with your doctor at the start of your visit:

"I am here today strictly for my ACA-mandated routine preventive wellness exam. Please let me know before ordering any tests or addressing symptoms that would be coded as diagnostic and subject to cost-sharing."