> For the complete documentation index, see [llms.txt](https://handbook.berrystreet.co/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://handbook.berrystreet.co/berry-street-provider-handbook/clinical-documentation-compliance-and-integrity-standards/preventative-and-medical-coverage.md).
# 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 Differences between Medical and Preventive Coverage](#key-difference)
* [Preventative Coverage Overview](#preventative-coverage)
* [Medical Coverage Overview](#medical-coverage)
* [Medical Nutrition Therapy (MNT) Coverage](#medical-nutrition-therapy-mnt-coverage)
#### **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\
---
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