One of the positive aspects of the Health Reform bill is the $0 Preventive Services benefit offered in Non-grandfathered plans (new plans beginning on or after September 23, 2010). If you are on a Non-grandfathered plan, a selection of preventive services must be covered without your having to pay a copayment or coinsurance or meet your deductible, when these services are delivered by a network provider. But how do you know if the service or test is considered Preventive or Diagnostic?
The easy and simple way to understand the general difference between preventive and diagnostic services is demonstrated by Mammography and Colonoscopy. For instance, if you receive your routine Mammogram according to schedule, it is considered a preventive exam. However if you find a lump and request a mammogram, then it is considered a diagnostic test subject to the coinsurance or copay your benefits plan offers. Similarly a colonoscopy is considered a preventive test when there are no symptoms or concerns and is performed to validate that the patient/member is healthy. If a problem has been brought to the attention of the doctor, then it is no longer considered preventive.
The Health Reform bill is working under interim rules; so many aspects have not been clearly defined. And insurance companies and/or doctors and facilities interpret the law differently, so many tests may not fall under the easy definition that a colonoscopy or a mammogram does. My best advice is to ask questions before the test and/or read your Explanation of Benefits (sometimes called EOB) carefully. If you don’t agree with your invoice or have questions about your medical bill, call the insurance company and then call the billing service where the procedure was performed to understand what and why you are charged. Now is the time to become an informed consumer in the medical field as well in other areas.
