HMSA plans cover a variety of tests that can fall under one of two categories: screening or diagnostic. The reason you’re taking a test determines the category. Screening and diagnostic tests have different plan benefits; diagnostic tests often have a higher copayment than screening tests. Since screening tests are considered preventive services, they’re usually covered at 100 percent of the eligible charge.
Diagnostic tests can be performed at any time, as long as there are symptoms and/or signs that suggest to your primary care provider that a condition or disease may be present and a test is needed to confirm the diagnosis.
Screening tests are recommended for people who don’t show symptoms and/or signs of a condition or disease, but may be at an increased risk based on their age, gender or other factors. Some common screening tests include Pap smears for women and colonoscopies for people age 50 and older.
Screening tests are preventive services that serve to detect disease in its early stages. Early detection generally offers the best opportunity for successful treatment.
When is a diagnostic test needed versus a screening test?
Let’s say a 52-year-old woman visits her physician because she has observed blood in her stool.
At age 52, she’s eligible for a screening colonoscopy, which is covered under her HMSA plan once every 10 years for members age 50 and older.
However, because she shows signs of a possible condition in her lower digestive system, her physician would order a diagnostic colonoscopy, which is covered as long as there are signs of a disease or condition that a colonoscopy may confirm.
On the other hand, let’s say the woman had no symptoms. One day during a routine visit, her family physician recommends she have a colonoscopy because she is eligible due to her age. Because she shows no signs of a possible condition, this would be considered a screening colonoscopy.