Thanks to theAffordable Care Act, most health plans in the U.S. have to cover certainpreventive health carewithout requiring you to pay adeductible, copayment, orcoinsurance. That rule applies to all non-grandfatheredmajor medical plans in the individual/family and employer-sponsored markets.

It’s important to understand how the preventive care rules work, what services are covered, and potential costs when you go to the doctor for a check-up.

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A pregnant woman discussing results with doctor

What Counts as Preventative Care?

There is a list of22 preventive care services for adultsthat must be provided without anycost-sharing, as long as you are receiving the service in line with the recommended preventive care guidelines.

Children have adifferent list, and there’s alsoan additional list of fully covered preventive services for women.

But keep in mind that you’ll need to use anin-network medical providerto obtain zero-cost preventive care.

Covered preventive care includes:

Cancer Prevention Measures

Infectious Disease Prevention Measures

Woman-Specific Preventive Care

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.

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.

The Advisory Committee on Immunization Practices (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).

Who Determines Which Preventive Care Benefits Are Covered?

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 determined as follows:

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 it does note that more research is needed, so it’s possible that the recommendation could change in the future.

Note 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.)

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.

When Your Health Plan Might Not Cover Preventive Care Without Cost-Sharing

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 amanaged carehealth plan that uses aprovider 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 anin-networkprovider.

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 youreceivepreventive care, the cost of those services is wrapped into the cost of your health insurance. Thus, whether or not you choose to get the recommendedpreventive care, you’re paying for it through the cost of your health insurance premiums anyway.

Summary

Under the Affordable Care Act, certain preventive care has to be covered in full (i.e., without a deductible, copay, or coinsurance) on all non-grandfathered major medical plans.

15 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.U.S. Centers for Medicare & Medicaid Services.Preventive care benefits for adults.Centers for Medicare and Medicaid Services.Affordable Care Act Implementation FAQs - Set 12 (See Q5). AndFAQS About Affordable Care Act Implementation Part 51.Rovner, Julie. Kaiser Health News.High Court Allows Employers To Opt Out of ACA’s Mandate On Birth Control Coverage.U.S. Center for Medicare and Medicaid Services.Coverage of Certain Preventive Services Under the Affordable Care Act: Proposed Rules. January 30, 2023.National Women’s Law Center.2023 & Free: You May Never Have to Pay for Condoms Again! February 1, 2023.Kaiser Family Foundation.2021 Employer Health Benefits Survey.Planned Parenthood.How do I get a vasectomy?Pollitz, Karen. Kaiser Family Foundation.Private Health Coverage of COVID-19: Key Facts and Issues.America’s Health Insurance Plans.Health Insurance Providers Respond to Coronavirus (COVID-19).American Cancer Society.Patient Groups Applaud Circuit Court Ruling That Largely Stays Remedy in Braidwood Management v. Becerra. June 13, 2023.Health Resources and Services Administration.Women’s Preventive Services Guidelines.Centers for Disease Control and Prevention.Advisory Committee on Immunization Practices (ACIP).U.S. Preventive Services Task Force.Final Recommendation Statement: Prostate Cancer: Screening.U.S. Preventive Services Task Force.Vitamin D Deficiency in Adults: Screening.Kaiser Family Foundation.2020 Employer Health Benefits Survey.

15 Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.U.S. Centers for Medicare & Medicaid Services.Preventive care benefits for adults.Centers for Medicare and Medicaid Services.Affordable Care Act Implementation FAQs - Set 12 (See Q5). AndFAQS About Affordable Care Act Implementation Part 51.Rovner, Julie. Kaiser Health News.High Court Allows Employers To Opt Out of ACA’s Mandate On Birth Control Coverage.U.S. Center for Medicare and Medicaid Services.Coverage of Certain Preventive Services Under the Affordable Care Act: Proposed Rules. January 30, 2023.National Women’s Law Center.2023 & Free: You May Never Have to Pay for Condoms Again! February 1, 2023.Kaiser Family Foundation.2021 Employer Health Benefits Survey.Planned Parenthood.How do I get a vasectomy?Pollitz, Karen. Kaiser Family Foundation.Private Health Coverage of COVID-19: Key Facts and Issues.America’s Health Insurance Plans.Health Insurance Providers Respond to Coronavirus (COVID-19).American Cancer Society.Patient Groups Applaud Circuit Court Ruling That Largely Stays Remedy in Braidwood Management v. Becerra. June 13, 2023.Health Resources and Services Administration.Women’s Preventive Services Guidelines.Centers for Disease Control and Prevention.Advisory Committee on Immunization Practices (ACIP).U.S. Preventive Services Task Force.Final Recommendation Statement: Prostate Cancer: Screening.U.S. Preventive Services Task Force.Vitamin D Deficiency in Adults: Screening.Kaiser Family Foundation.2020 Employer Health Benefits Survey.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

U.S. Centers for Medicare & Medicaid Services.Preventive care benefits for adults.Centers for Medicare and Medicaid Services.Affordable Care Act Implementation FAQs - Set 12 (See Q5). AndFAQS About Affordable Care Act Implementation Part 51.Rovner, Julie. Kaiser Health News.High Court Allows Employers To Opt Out of ACA’s Mandate On Birth Control Coverage.U.S. Center for Medicare and Medicaid Services.Coverage of Certain Preventive Services Under the Affordable Care Act: Proposed Rules. January 30, 2023.National Women’s Law Center.2023 & Free: You May Never Have to Pay for Condoms Again! February 1, 2023.Kaiser Family Foundation.2021 Employer Health Benefits Survey.Planned Parenthood.How do I get a vasectomy?Pollitz, Karen. Kaiser Family Foundation.Private Health Coverage of COVID-19: Key Facts and Issues.America’s Health Insurance Plans.Health Insurance Providers Respond to Coronavirus (COVID-19).American Cancer Society.Patient Groups Applaud Circuit Court Ruling That Largely Stays Remedy in Braidwood Management v. Becerra. June 13, 2023.Health Resources and Services Administration.Women’s Preventive Services Guidelines.Centers for Disease Control and Prevention.Advisory Committee on Immunization Practices (ACIP).U.S. Preventive Services Task Force.Final Recommendation Statement: Prostate Cancer: Screening.U.S. Preventive Services Task Force.Vitamin D Deficiency in Adults: Screening.Kaiser Family Foundation.2020 Employer Health Benefits Survey.

U.S. Centers for Medicare & Medicaid Services.Preventive care benefits for adults.

Centers for Medicare and Medicaid Services.Affordable Care Act Implementation FAQs - Set 12 (See Q5). AndFAQS About Affordable Care Act Implementation Part 51.

Rovner, Julie. Kaiser Health News.High Court Allows Employers To Opt Out of ACA’s Mandate On Birth Control Coverage.

U.S. Center for Medicare and Medicaid Services.Coverage of Certain Preventive Services Under the Affordable Care Act: Proposed Rules. January 30, 2023.

National Women’s Law Center.2023 & Free: You May Never Have to Pay for Condoms Again! February 1, 2023.

Kaiser Family Foundation.2021 Employer Health Benefits Survey.

Planned Parenthood.How do I get a vasectomy?

Pollitz, Karen. Kaiser Family Foundation.Private Health Coverage of COVID-19: Key Facts and Issues.

America’s Health Insurance Plans.Health Insurance Providers Respond to Coronavirus (COVID-19).

American Cancer Society.Patient Groups Applaud Circuit Court Ruling That Largely Stays Remedy in Braidwood Management v. Becerra. June 13, 2023.

Health Resources and Services Administration.Women’s Preventive Services Guidelines.

Centers for Disease Control and Prevention.Advisory Committee on Immunization Practices (ACIP).

U.S. Preventive Services Task Force.Final Recommendation Statement: Prostate Cancer: Screening.

U.S. Preventive Services Task Force.Vitamin D Deficiency in Adults: Screening.

Kaiser Family Foundation.2020 Employer Health Benefits Survey.

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