Federal law requires most health plans to cover many preventive services at no cost to you. Here is what that guarantee includes, where the loopholes are, and how to avoid an unexpected bill.
Most health plans in the United States are required to cover a set of recommended preventive services without charging you a deductible, copayment or coinsurance. The guarantee is real, but it comes with conditions, and people still get bills for visits they expected to be free. Knowing what the law requires, and where the gaps are, helps you keep the cost at zero.
Why many screenings cost nothing under the ACA
The Affordable Care Act, signed into law on March 23, 2010, requires most private health plans to cover preventive services with strong scientific evidence behind them and to eliminate cost-sharing for those services. The rules applied to new health policies beginning on or after September 23, 2010, and to policies renewing after that date. The federal government estimated that about 71 million Americans received expanded coverage of one or more preventive services in 2011 and 2012.
The requirement covers most plans, but not all. Plans purchased on or before March 23, 2010 may hold grandfathered status, which means they may not include some of the protections the law provides. The no-cost guarantee applies only when the service is delivered by a provider in your plan’s network.
Which services must be covered without a copay
For adults, HealthCare.gov lists covered preventive services that include blood pressure and cholesterol screening, colorectal cancer screening for adults 45 to 75, type 2 diabetes screening for adults 40 to 70 who are overweight or obese, hepatitis C screening for adults 18 to 79, lung cancer screening for adults 50 to 80 at high risk, and tobacco use screening with cessation interventions for tobacco users. Immunizations for adults are covered too, though recommended doses, ages and populations vary.
For women, required services include mammograms every 1 to 2 years for women 40 and older, well-woman visits, FDA-approved contraceptive methods and counseling, diabetes screening for women with a history of gestational diabetes, and hepatitis B screening for pregnant women at their first prenatal visit.
Some covered services are one-time tests. See our guide to once-in-a-lifetime screenings for what they involve.
Why you can still get a bill, and how to lower the odds
The law eliminates cost-sharing for the preventive service itself, but not every related charge. Bills most often come from one of these situations:
- Coding. If your clinician addresses a new symptom or an ongoing condition during the same visit, the practice may bill part of the visit as diagnosis or treatment rather than prevention, which can carry a copay or deductible.
- Follow-up testing. A screening that finds something can lead to diagnostic tests, and those may be billed as regular medical care.
- Network. If the lab, the imaging center or a second clinician involved in your visit is outside your plan’s network, the no-cost guarantee may not apply.
- Grandfathered plans. Some older plans are not required to follow the preventive coverage rules.
To lower the odds, confirm before the visit that the service is billed as preventive, that everyone involved accepts your insurance, and that the location is in your network.
Helpful tip
When you book, say plainly that you are scheduling a preventive visit, and ask the office to confirm it will be coded that way.
Special cases: Medicare, Medicaid and uninsured options
Medicare Part B covers a one-time “Welcome to Medicare” preventive visit within your first 12 months of Part B. You pay nothing for it if your provider accepts assignment, and the Part B deductible does not apply. You may owe coinsurance if your provider performs additional tests or services during the same visit that Medicare does not cover under this preventive benefit. Medicare may add preventive services through the National Coverage Determination process when the U.S. Preventive Services Task Force recommends them with a grade of A or B.
Medicaid coverage of preventive services differs by state, so check with your state agency for the specifics. If you are uninsured, a local federally qualified health center is a good place to start for preventive care.
Questions to ask your plan before you book
A short phone call to the number on your insurance card can prevent most surprises:
- Is this screening covered for someone my age and risk level without cost-sharing?
- Will my clinician, the lab and the facility all be in network?
- If my doctor discusses another health issue at the same visit, how will the claim be billed?
What to do if you get a preventive-care bill
Start by comparing the bill with your plan’s explanation of benefits and checking how the claim was coded. Then call the provider’s billing office and ask them to confirm the visit was coded as preventive. Coding errors happen, and many are fixed with one call. If the bill stands and you believe the service should have been covered, you can file an appeal with your plan.
If you do owe money for other care, there is a ceiling on how much your plan can require you to spend out of pocket in a year: no more than $10,600 for an individual or $21,200 for a family in 2026, and no more than $12,000 for an individual or $24,000 for a family in 2027.
Read our guide to what happens at a preventive checkup, and for one of the numbers checked at nearly every visit, see how blood pressure readings work.
Key points
- Most health plans must cover recommended preventive services with no copay, coinsurance or deductible when you use an in-network provider.
- Covered services include blood pressure and cholesterol checks, colorectal cancer screening from 45 to 75, and mammograms every 1 to 2 years for women 40 and older.
- Bills usually happen because the visit was coded as something other than preventive, a follow-up test was needed, or the provider was out of network.
- Medicare’s Welcome to Medicare visit is free if your provider accepts assignment, but extra tests during the visit can cost you.
- If you get a preventive-care bill, check the billing codes, ask the provider’s billing office to review them, and appeal if needed.
Common questions
Do I have to pay anything for covered preventive services?
Most plans must cover recommended preventive services without a copay, coinsurance or deductible, as long as the service is delivered by a provider in your plan’s network. Using an out-of-network provider removes that protection.
Why did I get a bill for a free screening?
Common reasons include billing codes that describe the visit as diagnosis or treatment rather than prevention, follow-up tests done the same day, or an out-of-network provider. Review the bill and your plan’s explanation of benefits, then ask the provider’s billing office to check how the claim was coded.
Does Medicare cover preventive visits?
Medicare Part B covers a one-time Welcome to Medicare preventive visit within your first 12 months of Part B. You pay nothing if your provider accepts assignment, but you may owe coinsurance for additional tests or services that Medicare does not cover under that benefit.
What if I do not have insurance?
Coverage rules for Medicaid differ by state, so check with your state agency. If you are uninsured, a federally qualified health center is a good place to start for preventive care.
This guide explains general U.S. screening recommendations and is not medical advice. Your clinician may recommend a different schedule based on your health, history and test results.