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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.
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:
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.
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.
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.
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.
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.
14 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
By Elizabeth Davis, RN
Elizabeth Davis, RN, is a health insurance expert and patient liaison. She's held board certifications in emergency nursing and infusion nursing.
