Insurance is a tricky and not always transparent business. Many people struggle to figure out what’s covered and what’s not. To make matters worse, even when something is covered, what you pay for a test could change based on how it’s labelled — screening or diagnostic. This is what you need to know about diagnostic tests.

Preventive Screening

As a family physician, prevention is key. A preventive approach to medicine looks to decrease the chance that you will get sick in the first place. Think about eating a balanced diet, exercising regularly, getting enough sleep, and maintaining healthy relationships.

Prevention screening is a twist on that. These tests look for conditions common in the general population or for someone in your situation based on age, gender, or genetics. The test is considered a screening test when you do not have any signs or symptoms at the time of the test. The goal is to diagnose a disease early enough so that it can be treated and potentially cured (depending on the condition), preventing or minimizing any complications.

Diagnostic Tests

Diagnostic tests, on the other hand, investigate any signs or symptoms you have in the here and now. In that case, there is concern that something may be wrong.

“Signs” are objective findings from a test that raise suspicion for a disease. For example, you could have abnormal laboratory or imaging studies. These findings may or may not be something you feel.

“Symptoms” are your subjective experience, physical or mental. They are something you feel firsthand.

What You Pay

The Affordable Care Act (ACA) expanded access to preventive screening nationwide. Specifically, the law added coverage for many screening tests that had a Grade A or Grade B rating by the U.S. Preventive Services Task Force (USPSTF). These grades are based on up-to-date reviews of the medical literature.

As long as you did not enroll in a grandfathered plan, i.e., one that existed before the ACA, you could get free screening tests in the following cases:

Original Medicare (Part A and Part B): Your healthcare provider accepts assignment. This means that they agree to charge no more than what Medicare recommends.

Health Insurance Marketplace plans, Medicare Advantage (Part C) plans, and other types of private health insurance: Your screening tests remain in network.

Unfortunately, preventive screening coverage for Medicaid varies by state. Check with your local Medicaid office.

Preventive Screening vs. Diagnostic Tests

It happens more than you think. Someone gets what they think is a “free” preventive screening test, but they end up with a bill. That’s because the same test performed for preventive screening gets billed as a diagnostic test when you have signs or symptoms. This could leave you to pay deductibles, coinsurance, or copays. The following shows examples of this in action. Please know this is not an all-inclusive list.

Breast Cancer Screening (Mammograms)

• Screening Recommendation: Mammogram screening once every 2 years for women between the ages of 50 and 74
• USPSTF Grade: B
• Diagnostic Tests: 1) You have a breast lump, nipple discharge, or others symptoms. -or- 2) There was an abnormality detected on your mammogram and another mammogram (or extra images) needs to be performed to get a better look. -or- 3) You have a personal history for breast cancer.

Medicare Tip:
Medicare is more generous than the USPSTF. You can get one screening mammogram between 35 and 39. You can then get screening every year starting at 40. There are no age restrictions beyond that.

Colon Cancer Screening (Colonoscopy)

• Screening Recommendation: Colonoscopy screening every 10 years for people 45 and older at average risk for colon cancer
• USPSTF Grade: B for people 45 to 49, A for people 50 to 75
• Diagnostic Tests: 1) You have blood in the stool, an unexplained change in bowel habits, or other symptoms. -or- 2) You are at high risk for colon cancer, i.e., you have inflammatory bowel disease, you or a family member has been diagnosed with a genetic disease that increases the risk for colon cancer, or you have a personal history for colon cancer. -or- 3) An adenomatous polyp was detected on a previous flexible sigmoidoscopy or colonoscopy. -or- 4) A polyp (of any type) is detected during what was initially ordered as a screening colonoscopy. The test becomes diagnostic so that the polyp can be removed and biopsied.

Medicare Tip:
You pay a 20% Part B coinsurance for most diagnostic tests but you will only pay a 15% coinsurance for a diagnostic colonoscopy.

Lung Cancer Screening (Low-Dose CT Scan)

• Screening Recommendations: Lung cancer with a low-dose CT scan every year for anyone 55 to 80 years old who has smoked 20-pack years (# of cigarette packs smoked each day multiplied by the # of years of smoking) AND who either still smokes or quit smoking within the past 15 years
• USPSTF Grade: B
• Diagnostic Tests: 1) You cough up blood, have an unexplained chronic cough, or have other symptoms. -or- 2) You had a lung nodule detected on a prior study, whether it was a low-dose CT scan or another test. Lung nodules that are small in size (< 6 mm) or that do not change size over time are unlikely to be cancerous. However, these nodules often require monitoring, and studies looking for any changes will be considered diagnostic.

Medicare Tip:
Despite the USPSTF recommendations, Medicare Part B only covers screening for people 50 to 77.

A System That Doesn’t Always Make Sense

There is a sad irony in all of this. The medical system looks for disease in people who may or may not have it. They do this for free. If they actually find something, they charge for it. When people need care the most, the American healthcare system pulls a bait and switch.

When someone is sick, it may be harder to hold a job or get employer-sponsored health insurance. People may qualify for Social Security Disability Insurance (SSDI) but unless they have ALS or end-stage renal disease, they have to wait 24 months to get on Medicare. It may be difficult for single people to get Medicaid support in states that have not expanded Medicaid. These are only some of the many issues that make it hard for millions of people to access care.

Free preventive screening is a first step. While we can’t expect healthcare providers, hospitals, and medical facilities to provide all of their care for free, we need to do more. We need a support network to protect vulnerable people and people in need. The time may be coming for the United States to consider what other developed nations have successfully done — universal health care.

 

Background: The Affordable Care Act’s New Rules on Preventive Care. Centers for Medicare & Medicaid Services. https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/preventive-care-background

Colonoscopy Screening Coverage. (2023). Medicare.gov. https://www.medicare.gov/coverage/colonoscopies

Gaga, M., Loverdos, K., Fotiadis, A., Kontogianni, C., & Iliopoulou, M. (2019). Lung nodules: A comprehensive review on current approach and management. Annals of Thoracic Medicine, 14(4), 226. https://doi.org/10.4103/atm.atm_110_19

Lung Cancer Screening Coverage. (2023). Medicare.gov. https://www.medicare.gov/coverage/lung-cancer-screenings

Mammogram Insurance Coverage. (2023). Medicare.gov. https://www.medicare.gov/coverage/mammograms

Preventive Care. HHS.gov. https://www.hhs.gov/healthcare/about-the-aca/preventive-care/index.html

Preventive Care Benefits for Adults. (2023). Healthcare.gov. https://www.healthcare.gov/preventive-care-adults/

Recommendation: Breast Cancer: Screening. (2016). United States Preventive Services Taskforce. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening

Recommendation: Colorectal Cancer: Screening. (2021). United States Preventive Services Taskforce. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening

Recommendation: Lung Cancer: Screening. (2021). United States Preventive Services Taskforce. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening