What Insurance Covers During Physicals

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South Shore Health

Deciphering a healthcare bill can be confusing

Health care costs and the bills you receive can be confusing. One common question revolves around what is and is not covered during annual physicals.

(A quick caveat: The information below applies to most health insurance policies. But it’s wise to check with your insurance company before a medical appointment if you have any questions on what’s covered and what isn’t.)

Insurance companies tend to view patient care in two buckets: Preventative care and diagnostic care.

Preventive care includes services such as checkups, screening tests, and immunizations—care that you get when you’re symptom-free and have no reason to believe you might be sick.

Diagnostic care is what you get when you have symptoms of an illness or injury or are being followed for a chronic condition, and your doctor wants to diagnose or monitor the condition. This may include an office visit, tests, or treatments.

Diagnostic and preventive care may occur during the same visit. For example, you may have a checkup during which your doctor discusses a chronic illness you have. Some of the tests ordered that day may be preventive (such as a screening mammogram) and others may be diagnostic (such as a blood sugar test for a diabetic).

Why it matters

Most health plans cover preventive care at no cost, with the exception of plans that have grandfathered status. (To check your preventive care benefits, call your health plan’s member service line—typically listed on the back of your health insurance card.)

But you may have to pay something for diagnostic care. And if both preventive and diagnostic care occur at the same visit, you may have to pay something (copayment, deductible, or co-insurance) for the diagnostic services.

Examples of What You May Pay for Preventative Care

“I just took my 6-month old for a well-baby visit, including her shots.”

You likely pay: Nothing. Most health plans cover preventive care at no cost, with the exception of plans that have grandfathered status.

“I’m a healthy 40-year old man and last Friday I had a routine physical. The doctor ordered many routine screenings, including lab tests to check my cholesterol.”

You likely pay: Nothing. Most health plans cover preventive care at no cost, with the exception of plans that have grandfathered status.

Examples of What You May Pay for Diagnostic Care

“I went skiing last week and hurt my knee. I went to the doctor and had an MRI, so he could diagnose the problem.”

You may have to pay something for the visit with the doctor, the MRI, and for the radiologist’s interpretation of the MRI. Depending on your plan, you may have a copayment, deductible, or co-insurance.

Examples of What You May Pay for Preventative and Diagnostic Care

“I was diagnosed with high cholesterol last year. Yesterday I went to see my doctor for a routine physical. During the visit, she also discussed my diet and medication, reviewed possible side-effects I could have from the medicine, and ordered lab work to monitor my condition.”

If your plan covers preventive care at no cost, you will pay nothing for the physical. You may have to pay something for your doctor’s time assessing your condition and for the cholesterol test.

“When I went to see my doctor for my annual checkup, I was wheezing. The doctor completed my checkup and then also treated me for the wheezing. She told me I have asthma, discussed treatment, and gave me some prescriptions.”

If your plan covers preventive care at no cost, you will pay nothing for the checkup. You may have to pay something for the doctor’s time in diagnosing and discussing your condition, even though you paid nothing for the checkup.

“I took my son to his well visit about two weeks after he had been seen for an ear infection. The pediatrician asked if my son had taken all of his antibiotics and whether his symptoms had improved. After looking in my son’s ears, the doctor said the infection was gone.”

If your plan covers preventive care at no cost, you will pay nothing for the well visit. And because the doctor checked your son’s ears as part of the checkup and there was minimal extra work to ask you about how your child did on medicine, the visit may be classified as only a preventive service and you wouldn’t have to pay an additional cost share.

If you have any questions about what your insurance will cover, call your health plan’s member service line.

To learn more about primary care at South Shore Health, click here.