Thanks to the Affordable Care Act, health insurers in the U.S. have to cover certain preventive health care without requiring you to pay a deductible, copayment, or coinsurance. That rule applies to all non-grandfathered major medical plans in both the individual/family and employer-sponsored markets.
This article will explain how the preventive care rules work, what services are covered, and what you need to be aware of in terms of potential costs when you go to the doctor for a check-up.
So, what exactly counts as preventive care? Here’s the list of preventive care services for adults that, if recommended for you by your healthcare provider, must be provided free of cost-sharing.
Children have a different list, and there’s also an additional list of fully covered preventive services for women.
As long as your health plan isn’t grandfathered (or among the types of coverage that aren’t regulated by the Affordable Care Act at all, such as short-term health insurance or fixed indemnity plans), any services on those lists will be fully covered by your plan, regardless of whether you’ve met your deductible or how long you’ve been enrolled.
But keep in mind that you’ll need to use an in-network medical provider in order to obtain zero-cost preventive care.
Preventive care is one of the ACA’s essential health benefits (EHBs). But it’s the only one that has to be covered with no cost-sharing. And it’s the only one that has to be covered by large group health plans; the rest of the EHBs only have to be covered on individual/family and small group health plans (although most large employer plans do tend to include all of the EHBs).
Covered preventive care includes:
Cancer prevention measures:
- Colorectal cancer related: for adults age 50 to 75, including screening colonoscopies, removal of polyps discovered during a screening colonoscopy, and anesthesia services required to perform the screening colonoscopy. Note that people do sometimes report being charged for polyp removal during a regular screening colonoscopy, but that is not allowed under federal rules. However, if the colonoscopy is being done in conjunction with any sort of symptoms, or if it’s being done more frequently than the normal schedule, it will be considered diagnostic rather than preventive, which means regular cost-sharing rules would apply. For example, if a colonoscopy is being done as a follow-up to a previous colonoscopy in which a polyp was found; doctors sometimes recommend a follow-up after three years, which would generally not be covered by health insurance, since that’s outside the regular screening guidelines of once per decade. It’s a good idea to thoroughly discuss colonoscopy coverage with your health insurer in order to make sure you fully understand what is and isn’t covered under the screening guidelines.
- Breast cancer related: including screening mammograms every 1-2 years for women over 40, BRCA genetic testing and counseling for women at high risk, and breast cancer chemoprevention counseling for women at high risk. As is the case for colonoscopies, mammograms are only covered with zero cost-sharing if they’re done purely as a screening measure. If you find a lump in your breast and your healthcare provider wants a mammogram to check it out, your health plan’s regular cost-sharing (deductible, copay, and/or coinsurance) will apply, since this will be a diagnostic mammogram rather than a screening mammogram. This will be true even if you’ve never had a mammogram before, or even if you’re due for your regularly-scheduled screening mammogram.
- Cervical cancer related: screening covered once every three years from ages 21 through 65; human papillomavirus DNA testing can instead be done in conjunction with a pap test once every five years.
- Lung cancer related: screening for smokers or those who’ve quit smoking within the last 15 years and are between the ages of 55 and 80
Infectious disease prevention measures:
- Hepatitis C screening one time for anyone born 1945-1965 and for any adult at high risk.
- Hepatitis B screening for pregnant women at their first prenatal visit, and for any adults considered at high risk.
- HIV screening for anyone between ages 15-65, and for others at high risk.
- Syphilis screening for adults at high risk and all pregnant women.
- Chlamydia screening for young women and women at high risk.
- Gonorrhea screening for women at high risk.
- Sexually transmitted infection prevention counseling for adults at increased risk.
- Routine immunizations as recommended by age for
- COVID-19 (recommendation was added in December 2020)
- Hepatitis A
- Hepatitis B
- Herpes Zoster(shingles)
- Human Papillomavirus
- Influenza (flu)
- Measles, Mumps, Rubella
- Tetanus, Diphtheria, Pertussis (lock-jaw and whooping cough)
- Varicella (chickenpox)
- Obesity screening and counseling.
- Diet counseling for adults at high risk for chronic disease.
- Recommended cardiovascular disease-related preventive measures, including cholesterol screening for high-risk adults and adults of certain ages, blood pressure screening, and aspirin use when prescribed for cardiovascular disease prevention (and/or colorectal cancer prevention) in adults ages 50 to 59.
- Diabetes type 2 screening for overweight adults age 40 to 70
- Abdominal Aortic Aneurysm screening one time for men who have ever smoked
Recommended substance abuse and mental health preventive care:
- Alcohol misuse screening and counseling
- Tobacco use screening and cessation intervention for tobacco users
- Depression screening
- Domestic violence and interpersonal violence screening and counseling for all women
Woman-Specific Preventive Care
- Well-woman visits for women under 65 (note that most Americans transition to Medicare at age 65, and Medicare has its own preventive care coverage).
- Osteoporosis screening for women over 60 based on risk factors.
- Contraception for women with reproductive capacity as prescribed by a healthcare provider. This includes all FDA-approved methods of female contraception, including IUDs, implants, and sterilization. The Supreme Court ruled in 2020 that employers with a “religious or moral objection” to contraception can opt out of providing this coverage as part of their group health plan. But the Biden administration has proposed a rule change that would eliminate the moral objection, and that would ensure access to zero-cost contraception for women whose employers have a religious objection. (Note that although male contraception is not a federally-mandated benefit, some states do require state-regulated health plans to cover vasectomies; state-regulated plans do not include self-insured plans, which account for the majority of employer-sponsored coverage.)
- Preventive services for pregnant or nursing women, including:
- Anemia screening
- Breastfeeding support and counseling including supplies
- Folic acid supplements for pregnant women and those who may become pregnant
- Gestational diabetes screening at 24 and 28 weeks gestation and those at high risk
- Hepatitis B screening at first prenatal visit
- Rh incompatibility screening for all pregnant women and follow up screening if at increased risk
- Expanded tobacco counseling
- Urinary tract or other infection screening
- Syphilis screening
Who Determines Which Preventive Care Benefits Are Covered?
So where did the government come up with the specific list of preventive services that health plans have to cover? The covered preventive care services are things that are:
All of the services listed above (and on the lists maintained by HealthCare.gov) meet at least one of those three guidelines for recommended preventive care. But those guidelines change over time, so the list of covered preventive care services can also change over time. For example, COVID vaccines were added to the list of covered preventive care in December 2020.
If there’s a specific preventive care treatment that you don’t see on the covered list, it’s probably not currently recommended by medical experts. That’s the case with PSA screening (it’s got a “C” or a “D” rating, depending on age, by USPSTF).
Vitamin D screening is another example of a preventive care service that isn’t currently recommended (or required to be covered). For now, the USPSTF has determined that there’s insufficient evidence to determine whether to recommend Vitamin D screening in asymptomatic adults. But they do note that more research is needed, so it’s possible that the recommendation could change in the future.
It’s also important to understand that when you go to your healthcare provider for preventive care, they might provide other services that aren’t covered under the free preventive care benefit. For example, if your healthcare provider does a cholesterol test and also a complete blood count, the cholesterol test would be covered but the CBC might not be (it would depend on your health plan’s rules, as not all of the tests included in the CBC are required to be covered).
And some care can be preventive or diagnostic, depending on the situation. Preventive mammograms are covered, for example, but your insurer can charge you cost-sharing if you have a diagnostic mammogram performed because you or your health provider find a lump or have a specific concern that the mammogram is intended to address.
Or if you need a follow-up screening sooner than the regular recommended screening guidelines (due to an issue that was found on the last screening test, for example), the follow-up may have your plan’s regular cost-sharing. If in doubt, talk with your insurer beforehand so that you’ll understand how your preventive care benefits work before the bill arrives.
Preventive Care Related to COVID-19
The COVID-19 pandemic gripped the world starting in early 2020. There’s normally a lengthy process (which can last nearly two years) involved with adding covered preventive services through the channels described above.
But Congress quickly took action to ensure that most health insurance plans would fully cover the cost of COVID-19 testing, although that only lasted through the end of the COVID public health emergency, which ended in May 2023.
And the legislation that Congress enacted in the spring of 2020—well before COVID-19 vaccines became available—ensured that once the vaccines did become available, non-grandfathered health plans would cover the vaccine nearly immediately, without any cost-sharing.
ACIP voted in December 2020 to add the COVID-19 vaccine to the list of recommended vaccines, and non-grandfathered health plans were required to add the coverage within 15 business days (well before the vaccine actually became available for most Americans).
That continues to be the case, even after the public health emergency has ended. Recommended COVID vaccines continue to be fully covered by non-grandfathered health plans, just like other recommended vaccines.
Obviously, the medical costs related to COVID-19 go well beyond testing. People who need to be hospitalized for the disease can face thousands of dollars in out-of-pocket costs, depending on how their health insurance plan is structured. Many health insurance companies opted to go beyond the basic requirements, temporarily offering to fully cover COVID-19 treatment, as well as testing, for a limited period of time. But those cost-sharing waivers had mostly expired by the end of 2020.
When Your Health Plan Might Not Cover Preventive Care Without Cost-Sharing
If your health insurance is a grandfathered health plan, it’s allowed to charge cost-sharing for preventive care. Since grandfathered health plans lose their grandfathered status if they make substantial changes to the plan, and can no longer be purchased by individuals or businesses, they’re becoming less and less common as time passes.
But there are still a substantial number of people with grandfathered health coverage; among workers who have employer-sponsored health coverage, 14% were enrolled in grandfathered plans as of 2020. Your health plan literature will tell you if your health plan is grandfathered. Alternatively, you can call the customer service number on your health insurance card or check with your employee benefits department.
If you have a managed care health plan that uses a provider network, your health plan is allowed to charge cost-sharing for preventive care you get from an out-of-network provider. If you don’t want to pay for preventive care, use an in-network provider.
Also, if your health plan is considered an “excepted benefit,” it’s not regulated by the Affordable Care Act and thus not required to cover preventive care without cost-sharing (or at all). This includes coverage such as short-term health plans, fixed indemnity plans, healthcare sharing ministry plans, and Farm Bureau plans in states where they’re exempted from insurance rules.
Preventive Care Isn’t Really Free
Although your health plan must pay for preventive health services without charging you a deductible, copay, or coinsurance, this doesn’t really mean those services are free to you. Your insurer takes the cost of preventive care services into account when it sets premium rates each year.
Although you don’t pay cost-sharing charges when you receive preventive care, the cost of those services is wrapped into the cost of your health insurance. This means, whether or not you choose to get the recommended preventive care, you’re paying for it through the cost of your health insurance premiums anyway.
Under the Affordable Care Act, certain preventive care has to be covered in full (ie, without a deductible, copay, or coinsurance) on all non-grandfathered major medical plans. Covered preventive care includes a long list of services that are recommended by medical experts, although it does not include all medical care that’s considered preventive. And some services, such as mammograms, pap test, or colonoscopies—can be fully paid for by the health plan or not. Coverage will depend on whether they’re done at regular screening intervals without any symptoms, or to diagnose a problem or follow-up after a previous test returned abnormal results.
A Word From Verywell
Your health plan likely covers a wide range of preventive services at no cost to you, and it’s in your best interest to take advantage of these benefits. But to avoid being surprised by an unexpected medical bill, you’ll want to be sure you understand the details prior to receiving preventive care. Make sure you use a provider who is in your health plan’s network, and make sure you understand exactly what tests or services will be provided during the visit. If you decide to go beyond what your health plan will cover, that’s perfectly fine and is a decision you’ll make with your medical provider.