Preventive care is the category of services an insurance plan must cover without cost sharing when delivered in network: no copay, no coinsurance, and no requirement to meet the deductible first. Screenings, annual wellness visits, recommended immunizations and counselling for certain conditions sit inside it.

The category is defined by recommendation, and recommendations are specific to age, sex and risk group. A screening that is preventive for one person at one interval is not automatically preventive for another.

What catches people is that the same physical service can fall inside or outside the category depending on why it was ordered. A cholesterol panel as routine screening is preventive. The identical panel ordered to monitor a diagnosed condition is diagnostic, and normal cost sharing applies. A colonoscopy at the screening interval is preventive; one ordered because of symptoms is not. Nobody explains this at the desk, and the two situations are indistinguishable from the patient’s chair.

The useful question, asked before the service: “Is this being ordered and coded as preventive screening or as diagnostic?”

In New York: two rules inside this category are worth knowing because they are billed wrong so often. Removing a polyp during a screening colonoscopy does not turn it into a paid procedure — federal guidance is explicit that plans may not impose cost sharing for it. And a colonoscopy after a positive stool-based test is still a screening, covered with no cost sharing, because it completes a screening rather than starting a new episode. If a bill arrives in either situation, the correct first assumption is that the claim was processed incorrectly.

Two boundaries. The no-cost-sharing rule attaches to in-network delivery, so an out-of-network provider can bill you for the same preventive service. And it is an insurance rule, so it does nothing on its own for an uninsured patient, who should instead look at hospital financial assistance and sliding-scale community health centers.

Also called: preventive services, screening, wellness visit. Full guide: What a colonoscopy costs, and the rule that makes a screening free.

More in Glossary of health coverage and billing terms

  • Formulary — A formulary is a plan's list of covered drugs, sorted into tiers that set your cost. What on-formulary means, how exceptions work, and New York's NYRx list.
  • Prior authorization — Prior authorization is a plan's approval before it pays for care. Who asks for it, what a denial says, where the deadlines are, and New York's appeal route.
  • Explanation of benefits (EOB) — An explanation of benefits (EOB) is your plan's record of a claim, not a bill. How to read each line, which one a bill must match, and what a denial means.
  • Deductible — A deductible is what you pay for covered care each plan year before your plan pays its share. How it works, what skips it, and which New York plans have none.
  • Copay — A copay is a fixed amount you pay for a covered service. How it differs from coinsurance, when the deductible comes first, and the copay rules New York adds.

This page explains how the system works. It is not medical advice. More.