Health insurance plans sold or renewed after 2010 must cover a long list of preventive care services at no cost to you, with no deductible, co-pay, or co-insurance when you see an in-network provider. The preventive care services covered by health insurance include cancer screenings, immunizations, contraception, well-child and well-woman visits, HIV prevention medication, and dozens of other screenings and counseling services. The catch is in the details: out-of-network providers, grandfathered plans, and visits that shift from preventive to diagnostic can all still generate a bill.
Who Decides What Counts as Preventive
Section 2713 of the Public Health Service Act, added by the Affordable Care Act, requires non-grandfathered health plans to cover certain preventive services without charging the patient.1Office of the Law Revision Counsel. 42 USC 300gg-13 – Coverage of Preventive Health Services The law itself names no services. It points instead to four expert bodies, and plans must follow their recommendations:
- The U.S. Preventive Services Task Force (USPSTF) grades screenings and counseling for adults. Services graded “A” or “B” must be covered at no cost.2U.S. Preventive Services Task Force. Grade Definitions
- The Advisory Committee on Immunization Practices (ACIP) sets the recommended vaccine schedule for all ages.
- The Health Resources and Services Administration’s Bright Futures guidelines govern pediatric well-child visits from birth through age 21.3Health Resources and Services Administration. Bright Futures
- HRSA’s Women’s Preventive Services Guidelines cover preventive needs specific to women, including contraception and breastfeeding support.4Health Resources and Services Administration. Women’s Preventive Services Guidelines
The USPSTF’s role was challenged in court. The Supreme Court decided in June 2025 that USPSTF members are properly appointed, keeping the preventive care mandates in place.5Supreme Court of the United States. Kennedy v. Braidwood Management, Inc.
Screenings and Services Covered for Adults
Cancer Screenings
Colorectal cancer screening is covered for adults starting at age 45. Ages 50 to 75 carry a Grade A recommendation, ages 45 to 49 a Grade B.6United States Preventive Services Task Force. Colorectal Cancer – Screening One detail that catches people off guard works in your favor: if polyps are found and removed during a screening colonoscopy, your plan cannot charge cost-sharing for the removal. Federal guidance treats it as part of the screening.7Centers for Medicare & Medicaid Services. Affordable Care Act Implementation FAQs – Set 12
Lung cancer screening with low-dose CT is covered annually for adults 50 to 80 who have a 20 pack-year smoking history and currently smoke or quit within the past 15 years.8United States Preventive Services Task Force. Lung Cancer – Screening A pack-year equals about one pack a day for a year, so two packs daily for 10 years qualifies.
Heart and Metabolic Health
Blood pressure screening is covered for all adults. Cholesterol screening is covered for adults of certain ages or at increased cardiovascular risk. Type 2 diabetes screening is covered for adults ages 35 to 70 who are overweight or obese.9US Preventive Services Task Force. Screening for Prediabetes and Type 2 Diabetes
Statins for heart disease prevention are also a covered preventive service, not just a screening. Adults 40 to 75 with at least one cardiovascular risk factor and an estimated 10-year cardiovascular risk of 10% or greater qualify for no-cost statin coverage.10United States Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults – Preventive Medication
Behavioral Health
Depression screening is covered for all adults. Anxiety screening carries a B recommendation for adults 19 to 64. Alcohol misuse screening with brief counseling is covered for all adults, as is tobacco cessation counseling and intervention.
Immunizations
All vaccines on the ACIP-recommended adult schedule are covered without cost-sharing: the annual flu shot, Hepatitis A and B for adults meeting risk criteria, Tdap boosters, shingles vaccines, and updated COVID-19 vaccines.1Office of the Law Revision Counsel. 42 USC 300gg-13 – Coverage of Preventive Health Services
HIV Prevention (PrEP)
Pre-exposure prophylaxis for HIV carries the USPSTF’s A grade for adolescents and adults at increased risk.11United States Preventive Services Taskforce. Prevention of Acquisition of HIV – Preexposure Prophylaxis Oral tenofovir-based pills and injectable cabotegravir are covered. Plans must also cover the surrounding care without cost-sharing: HIV testing every three months, Hepatitis B and C testing, kidney function testing, STI screening at multiple body sites, pregnancy testing where relevant, and the office visits needed to prescribe and monitor the medication.12U.S. Department of Labor. FAQs About Affordable Care Act Implementation Part 47
Preventive Services for Women
Well-woman visits provide a yearly comprehensive check-up covering reproductive and general health, with no cost-sharing.
Screening mammograms are covered every two years for women ages 40 to 74.13United States Preventive Services Taskforce. Breast Cancer – Screening Cervical cancer screening runs on an age-based schedule: ages 21 to 29 get a Pap test every three years; ages 30 to 65 can choose a Pap test every three years, an HPV test every five years, or both together every five years.14U.S. Preventive Services Task Force. Cervical Cancer – Screening Screening stops after age 65 for women with adequate prior screening history and no high-risk factors, and after a hysterectomy that removed the cervix (absent a history of high-grade precancerous changes).
Gestational diabetes screening is covered for pregnant women at 24 weeks or later, with testing typically done between weeks 24 and 28.15U.S. Preventive Services Task Force. Gestational Diabetes – Screening Breastfeeding support, including lactation consultations and breast pumps, is covered for new mothers.
Contraception is a mandated preventive benefit. Plans must cover the full range of FDA-approved contraceptive methods, counseling, and sterilization procedures without cost-sharing.16U.S. Department of Labor. FAQs about Affordable Care Act Implementation Part 64 Certain religious employers like churches may be exempt, and some religiously affiliated nonprofits can use an accommodation that shifts contraceptive coverage to a third party.17HealthCare.gov. Birth Control Benefits
Preventive Services for Children and Adolescents
Pediatric preventive care follows the Bright Futures schedule from infancy through age 21.3Health Resources and Services Administration. Bright Futures Well-child visits include physical exams, growth tracking, and age-appropriate behavioral and developmental assessments. Hearing and vision screenings are covered throughout childhood, along with screenings for lead exposure, iron deficiency, and obesity. Every ACIP-recommended childhood vaccine is covered without cost-sharing, from the infant series through adolescent boosters.
If You Have a High-Deductible Plan
A high-deductible health plan paired with a health savings account doesn’t change your preventive care rights. Federal law lets HDHPs cover preventive services before the deductible without losing their HDHP status, and virtually all do.18Internal Revenue Service. IRS Notice 2024-75
The IRS has expanded what counts as “preventive care” for HDHP purposes beyond the standard ACA list. Since 2019, HDHPs can cover certain treatments for chronic conditions before the deductible, including insulin and glucose monitors for diabetes, inhalers for asthma, blood pressure monitors for hypertension, statins for heart disease, and SSRIs for depression, when prescribed to manage a diagnosed condition.19Internal Revenue Service. IRS Notice 2019-45 More recent guidance added over-the-counter contraceptives, male condoms, breast cancer screening services like MRIs and ultrasounds, and certain continuous glucose monitors to the HDHP preventive care list.18Internal Revenue Service. IRS Notice 2024-75
When You Can Still Be Charged
Out-of-Network Providers
The zero-cost guarantee depends on using an in-network provider. If you see an out-of-network doctor or facility for the same screening, your plan can apply co-pays, co-insurance, or your deductible.20Centers for Medicare & Medicaid Services. Background – The Affordable Care Act’s New Rules on Preventive Care Before any preventive appointment, confirm the provider is in-network through your insurer’s directory or member services. Pay attention to the lab processing your blood work and any specialist you’re referred to; a primary care doctor can be in-network while the lab isn’t.
When the Visit Turns Diagnostic
Preventive care means screening when you have no symptoms. The moment you raise a specific symptom or your doctor investigates an existing concern, that part of the visit can be billed as diagnostic, which is subject to your usual cost-sharing.
A single visit can carry two billing codes: one preventive (free) and one diagnostic (subject to deductible and co-insurance). Schedule your annual physical, mention persistent knee pain, and the knee evaluation may be documented and billed separately. The physical remains free; the knee exam can trigger a co-pay.
There’s a protection built in for office visit fees. When the primary purpose of your visit is a preventive service, your plan cannot tack on a separate office visit fee as long as the two aren’t billed independently. If your doctor also addresses a different medical issue during the same appointment, billing for that extra work is permitted.
To protect yourself: say clearly when scheduling that the visit is preventive, think twice before introducing new symptoms at a preventive appointment, and review your Explanation of Benefits afterward. A billing code entered wrong is fixable.
Grandfathered Plans
Plans that existed on or before March 23, 2010 and haven’t made certain significant changes since are grandfathered and exempt from the preventive services mandate.21HealthCare.gov. Grandfathered Health Insurance Plans They can still charge co-pays or deductibles for routine screenings.22U.S. Department of Labor. Application of Health Reform Provisions to Grandfathered Plans These plans are increasingly rare because most changes to cost-sharing, benefits, or employer contributions end the status. Your plan’s Summary of Benefits and Coverage must disclose whether the plan is grandfathered.
If You’re Billed for Something That Should Be Free
Non-grandfathered plans must offer an internal appeals process and must tell you why a claim was denied and how to appeal.23Centers for Medicare & Medicaid Services. Appealing Health Plan Decisions Internal appeal deadlines run 72 hours for urgent care, 30 days for non-urgent care not yet received, and 60 days for services already provided. If the internal appeal fails, you can request an independent external review, and a reviewer siding with you can force the insurer to cover the service.
Most denials of preventive care come from billing-code errors rather than deliberate refusals. The service may have been coded as diagnostic, or under a code that doesn’t match the USPSTF or ACIP recommendation. Call your provider’s billing office first and ask them to review the codes; a corrected claim resubmitted to the insurer is usually faster than a formal appeal.