🏥Preventative & Medical Coverage
Understanding the difference between preventative coverage and medical coverage is essential for providers. It helps you guide patients effectively, collaborate with support staff, and ensure both teams can leverage available benefits to maximize insurance coverage for each patient.
👉 This section covers:
Key Difference:
Preventative coverage aims to prevent illness or detect it early.
Medical coverage addresses existing health issues or ongoing medical needs.
At a glance:
Preventative services are often free or low-cost to the patient.
Medical coverage typically involves co-pays, deductibles, or co-insurance.
Preventative care helps reduce the need for more expensive treatments later, while medical coverage supports patients when those needs arise.
Using both together supports long-term health and cost management.
Preventative Coverage
Preventative coverage includes proactive services designed to maintain health, prevent disease, and identify conditions early. These services are intended to keep patients well and reduce the risk of future complications.
Examples include:
Routine screenings and tests (e.g., blood pressure, cholesterol, mammograms, colonoscopies)
Immunizations and vaccines (e.g., flu shot, HPV, tetanus)
Wellness visits and check-ups (e.g., annual physicals, prenatal care)
Counseling and education (e.g., smoking cessation, nutrition counseling, weight management, gym memberships)
Under the Affordable Care Act (ACA), most preventative services are covered at no cost to patients when provided by in-network providers.
Medical Coverage
Medical coverage (also referred to as “sick care” or “treatment coverage”) applies when a health condition, illness, or injury requires diagnosis or management. This coverage is reactive, addressing medical needs as they arise.
Examples include:
Office visits for illness or injury (e.g., infection, pain, colds)
Hospitalization or emergency care (e.g., surgery, ER visits, inpatient stays)
Management of chronic conditions (e.g., diabetes, heart disease)
Prescription medications (usually separate coverage with a co-pay or deductible)
Medical coverage may include co-pays, deductibles, and co-insurance, depending on the specific plan. (See Defining Insurance Terms section for more details.)
Medical Nutrition Therapy (MNT) Coverage
MNT Coverage Is Diagnosis-Specific
Medical Nutrition Therapy (MNT) provided by a Registered Dietitian Nutritionist (RDN) or Certified Nutrition Specialist (CNS) is covered under medical benefits when it meets the plan’s criteria for medical necessity. Coverage varies based on diagnosis, plan, and region.
Diagnoses Not Typically Covered for MNT
MNT is not usually covered for conditions that do not meet criteria for medical necessity. These include:
Mental health diagnoses (e.g., anxiety, depression, ADHD, bipolar disorder, substance use)
Sports nutrition or performance-focused counseling
General food sensitivities or intolerances (e.g., lactose intolerance, gluten sensitivity) unless tied to a broader diagnosis such as celiac disease or IBS
Disordered eating without a formal eating disorder diagnosis
Hormonal imbalances, asthma, bloating, gout, sleep apnea, endometriosis, arthritis
Diagnoses Commonly Covered for MNT
MNT is generally covered for chronic or medically managed conditions, including:
Diabetes and prediabetes
Chronic kidney disease (CKD)
Obesity and overweight
Cardiovascular disease (CVD)
Hypertension (HTN)
Hyperlipidemia
Digestive disorders (e.g., IBS, Crohn’s, IBD)
Eating disorders (e.g., anorexia, bulimia, ARFID)
Pregnancy-related conditions (e.g., gestational diabetes, complications)
Cancer and treatment-related nutrition needs
Additional diagnoses may be verified by the support team during benefits checks.
Last updated