Preventive care is the set of screenings, vaccinations, and counseling services that federal law requires most health plans to cover at no out-of-pocket cost when you see an in-network provider. Under the Affordable Care Act, what is considered preventive care is defined by four federal sources: services with a Grade A or B recommendation from the United States Preventive Services Task Force (USPSTF), immunizations recommended by the Advisory Committee on Immunization Practices (ACIP), and two sets of guidelines from the Health Resources and Services Administration (HRSA) covering children and women.1Office of the Law Revision Counsel. 42 USC 300gg-13 – Coverage of Preventive Health Services If a service appears on one of those lists, your plan generally cannot charge you a copay, coinsurance, or deductible for it.
A Grade A rating from the USPSTF means the evidence strongly supports a substantial health benefit. Grade B means the evidence supports at least a moderate benefit.2United States Preventive Services Task Force. Grade Definitions Anything graded lower than B isn’t part of the mandate, even if a doctor recommends it.
Screenings Covered for Adults
Most of the preventive care adults actually use comes from the USPSTF list. The services below are the ones that touch the largest number of people.
Heart, Blood Pressure, and Diabetes
Blood pressure screening is a Grade A recommendation for every adult 18 and older. The USPSTF suggests annual checks for people 40 and over and for those at higher risk, including Black adults and adults who are overweight. Adults 18 to 39 who aren’t at elevated risk and have had a normal reading can be screened every three to five years.3United States Preventive Services Task Force. Screening for Hypertension in Adults Recommendation Statement
Prediabetes and type 2 diabetes screening is recommended for adults aged 35 to 70 who are overweight or obese. Clinicians should consider earlier screening for people in populations with disproportionately high diabetes rates, and should apply a lower body-mass-index threshold for Asian American adults.4United States Preventive Services Task Force. Screening for Prediabetes and Type 2 Diabetes
Statin medications for the primary prevention of heart disease carry a Grade B recommendation for adults aged 40 to 75 who have at least one cardiovascular risk factor (high cholesterol, diabetes, high blood pressure, or smoking) and a 10-year cardiovascular event risk of 10 percent or greater.5United States Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults
Cancer Screenings
Colorectal cancer screening is recommended for all adults aged 45 to 75 and is Grade A for most of that range. For adults 76 to 85, screening is individualized.6United States Preventive Services Task Force. Colorectal Cancer Screening Several methods qualify, including colonoscopy, stool-based tests, and flexible sigmoidoscopy. A colonoscopy performed as a screening must be covered without cost-sharing.
Lung cancer screening with low-dose CT is recommended annually for adults aged 50 to 80 who have a 20-pack-year smoking history and currently smoke or quit within the past 15 years. Screening ends once someone has been smoke-free for 15 years.7United States Preventive Services Task Force. Lung Cancer Screening
Infectious Disease
Screening for chlamydia and gonorrhea is a Grade B recommendation for all sexually active women aged 24 and younger, and for older women at increased risk.8United States Preventive Services Task Force. Chlamydia and Gonorrhea Screening
HIV pre-exposure prophylaxis (PrEP) must be covered without cost-sharing for people who don’t have HIV but face exposure risk. The coverage includes the clinic visits and lab work needed to prescribe and monitor PrEP, not just the medication.9HIV.gov. The Affordable Care Act and HIV/AIDS
Mental Health and Substance Use
Depression screening is recommended for all adults aged 19 and older, including pregnant and postpartum individuals and older adults. The USPSTF gives this a Grade B rating and recommends screening even without known risk factors.10United States Preventive Services Task Force. Depression and Suicide Risk in Adults Screening
Screening for unhealthy alcohol use is Grade B for adults 18 and older, including pregnant women. Plans must also cover brief behavioral counseling for anyone identified as drinking at risky levels.11United States Preventive Services Task Force. Unhealthy Alcohol Use in Adolescents and Adults Screening and Behavioral Counseling Interventions
Adult Vaccines
Immunizations are covered under a separate legal track from the USPSTF process. Any vaccine recommended by ACIP must be provided without cost-sharing. For adults, that routinely includes the annual flu shot and a Tdap booster every 10 years, along with vaccines for shingles, pneumococcal disease, hepatitis B, and others depending on age, health status, and risk factors.12Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule for Ages 19 Years or Older
Preventive Services for Women
Women’s preventive care draws from the USPSTF list and from a separate set of HRSA-supported Women’s Preventive Services Guidelines. The HRSA guidelines fill gaps the USPSTF hasn’t addressed or that need women-specific parameters.
Breast and Cervical Cancer
Under the HRSA guidelines, mammography should begin no earlier than age 40 and no later than age 50, occurring at least every two years and as often as annually. Screening should continue through at least age 74, and age alone should not be the reason to stop.13Federal Register. Update to the HRSA-Supported Womens Preventive Services Guidelines
Cervical cancer screening is recommended for women aged 21 to 65. Women 21 to 29 should get a Pap test every three years. Women 30 to 65 have three options: a Pap test every three years, an HPV test every five years, or both together every five years.14United States Preventive Services Task Force. Cervical Cancer Screening
Osteoporosis Screening
Bone density screening is Grade B for women 65 and older. Postmenopausal women younger than 65 who have risk factors for osteoporosis also qualify based on a clinical risk assessment.15United States Preventive Services Task Force. Osteoporosis to Prevent Fractures Screening
Pregnancy-Related Care
Gestational diabetes screening is covered after 24 weeks of gestation, ideally between 24 and 28 weeks. Women with risk factors for type 2 diabetes should be screened earlier, preferably at the first prenatal visit.16Federal Register. Update to the HRSA-Supported Womens Preventive Services Guidelines Relating to Screening for Diabetes in Pregnancy Folic acid supplementation, prenatal visits, and screenings for conditions like preeclampsia are also part of the no-cost preventive package.
Contraception
All FDA-approved contraceptive methods must be covered without cost-sharing, along with sterilization procedures, patient counseling, and follow-up care. Covered methods include implants, intrauterine devices, injectables, oral contraceptives, patches, rings, barrier methods, and emergency contraception.17Federal Register. Update to the Womens Preventive Services Guidelines
Plans sponsored by certain religious employers may be exempt. A 2025 federal district court vacated expanded religious and moral exemptions issued in 2018, but further litigation is possible. If your employer claims a religious exemption, ask your plan administrator what contraceptive coverage you have.
Preventive Care for Children and Adolescents
Pediatric preventive care runs on the Bright Futures schedule, which HRSA supports with the American Academy of Pediatrics. Bright Futures maps well-child visits from birth through age 21, with physical exams, developmental assessments, and age-appropriate screenings at each stage.18Health Resources and Services Administration. Bright Futures ACA-covered plans must cover these visits with no out-of-pocket costs.19Federal Register. Update to the Bright Futures Periodicity Schedule
Built into the schedule: lead testing for children at risk of exposure, routine vision and hearing checks, and behavioral and developmental assessments. Families shouldn’t see charges for these when they stay on the recommended visit schedule and use in-network providers.
Childhood immunizations follow the ACIP schedule. Covered vaccines include MMR, DTaP, polio, hepatitis B, and varicella, among others.20Centers for Disease Control and Prevention. Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger
Counseling That Counts as Preventive
Not every preventive service is a lab test or an imaging study. Federal rules treat certain counseling the same way they treat a mammogram.
Tobacco cessation support is a Grade A recommendation. Plans must cover behavioral counseling and FDA-approved cessation medications for adults who use tobacco, and behavioral interventions for pregnant persons.21United States Preventive Services Task Force. Tobacco Smoking Cessation in Adults Including Pregnant Persons
Intensive behavioral interventions for obesity are recommended for adults with a BMI of 30 or higher. These are multi-session programs focused on diet, physical activity, and behavior change.22United States Preventive Services Task Force. Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults Nutritional counseling for people at elevated risk of chronic disease falls under the same umbrella.
When “Free” Preventive Care Isn’t Free
The zero-cost-sharing guarantee has real limits, and this is where most billing surprises happen.
Preventive vs. Diagnostic Billing
The line between “preventive” and “diagnostic” turns on why a service was performed, not what was done. A colonoscopy scheduled as a routine screening for a 50-year-old is preventive. The same procedure done because of bleeding or abdominal pain can be billed as diagnostic, with the usual deductible and coinsurance. The same logic applies to office visits: if you raise a new complaint during an annual wellness visit, part of the appointment may be coded as diagnostic and billed separately.
Medicare treats polyp removal during a screening colonoscopy as a cost-sharing event, charging 15 percent coinsurance for the provider’s services and potentially a facility fee.23Medicare.gov. Colonoscopies Screening Private ACA plans generally cannot impose cost-sharing when a polyp is removed during a screening colonoscopy, but rules diverge by plan type. Ask your insurer before the procedure if you need certainty.
Out-of-Network Providers
The no-cost-sharing rule applies only when you use an in-network provider.24HealthCare.gov. Preventive Health Services If you see an out-of-network doctor for a screening that would otherwise be free, your plan can charge you the full amount. This bites hardest with lab work: your doctor may be in-network while the lab their office uses is not.
Grandfathered Plans
Plans that existed before March 23, 2010, and haven’t made substantial changes to their benefits or cost structure can keep “grandfathered” status. Grandfathered plans are not required to cover preventive services at no cost.25HealthCare.gov. Grandfathered Health Insurance Plans Your plan has to tell you if it’s grandfathered.
If You Get Billed for Something That Should Be Preventive
You have a legal right to challenge the charge through a two-step process: an internal appeal, then an external review.
File your internal appeal within 180 days of the denial notice. Your insurer has 30 days to decide an appeal involving prior authorization, or 60 days for a service you already received. Urgent cases get a 72-hour turnaround.26Centers for Medicare and Medicaid Services. Has Your Health Insurer Denied Payment for a Medical Service
If the internal appeal fails, request an external review within 60 days. An independent reviewer examines the claim, and the insurer is bound by the result. External reviews are decided within 60 days, or within four business days for urgent cases.26Centers for Medicare and Medicaid Services. Has Your Health Insurer Denied Payment for a Medical Service Most preventive care denials come down to billing codes, where a service was coded as diagnostic rather than preventive. Ask your doctor’s office to confirm the correct preventive code in writing before you file.