Preventive Care at No Cost

One of the most significant consumer protections in the Affordable Care Act is the requirement that most health plans cover certain preventive services at no cost — no copay, no deductible. This means you can get recommended screenings, vaccines, and counseling without paying anything out of pocket at an in-network provider. Understanding how this benefit works in practice — which services qualify, which plans are covered, and how to avoid accidentally triggering cost-sharing — helps you use it effectively.

The legal basis: ACA Section 2713

Section 2713 of the Public Health Service Act, added by the ACA, requires non-grandfathered health plans to cover preventive services without cost-sharing — that is, without deductibles, copays, or coinsurance. The services that qualify come from three authoritative bodies:

1. U.S. Preventive Services Task Force (USPSTF): Recommendations with an A or B grade for adults and adolescents. These grades indicate that the evidence strongly supports the net benefit of the service for the described population.

2. Advisory Committee on Immunization Practices (ACIP): Vaccines recommended for children, adolescents, and adults by the CDC’s ACIP. This is the source of the childhood immunization schedule.

3. Health Resources and Services Administration (HRSA): Guidelines for women’s preventive services (comprehensive preventive care and screenings beyond USPSTF recommendations) and Bright Futures guidelines for pediatric preventive care.

Plans must cover services from all three sources at no cost when provided by an in-network provider.

Examples of covered preventive services

Screenings and tests:

• Blood pressure measurement
• Cholesterol screening
• Colorectal cancer screening (colonoscopy, stool tests, CT colonography at appropriate ages and risk levels)
• Lung cancer screening (low-dose CT) for adults with a significant smoking history
• Breast cancer screening mammography
• Cervical cancer screening (Pap smear, HPV testing)
• Diabetes screening
• Depression screening
• HIV screening
• Hepatitis C screening for adults born between 1945 and 1965 and others at risk
• Sexually transmitted infection screening

Vaccines: All ACIP-recommended vaccines, including influenza, COVID-19 (when recommended), shingles (Zoster), pneumococcal, Tdap (tetanus, diphtheria, pertussis), and others.

Counseling:

• Tobacco cessation counseling and approved cessation medications
• Obesity counseling and referral
• Alcohol misuse counseling
• Healthy eating and weight management counseling for cardiovascular risk
• Preconception and prenatal counseling at defined recommendations
• Preventive medication for cardiovascular risk (statins for eligible patients)

Women’s preventive services:

• Contraception (all FDA-approved methods, though litigation has affected some plan requirements — check with your insurer)
• Breastfeeding support and supplies
• Gestational diabetes screening
• Domestic violence screening and counseling
• Folic acid supplementation for women planning pregnancy

Pediatric preventive services: Well-child visits at defined ages, developmental screening, fluoride supplementation, vision and hearing assessment, and others per Bright Futures guidelines.

Ensuring you receive the no-cost benefit

Several situations can result in cost-sharing even when the service should be free:

Out-of-network providers: The no-cost requirement applies to in-network providers. If you see an out-of-network provider for a preventive service, normal out-of-network cost-sharing will apply. Always verify the provider is in-network before your visit.

Preventive visit that becomes a treatment visit: If you arrive for an annual physical and your provider addresses a specific symptom, complaint, or condition during the same appointment, the provider may bill two separate components — one as preventive (covered at no cost) and one as a diagnostic or treatment encounter (subject to cost-sharing). This is a common source of unexpected bills. If you want your visit to remain purely preventive, tell your provider you are there for a wellness exam only and that you would prefer to schedule any additional concerns at a separate visit.

Grandfathered or short-term plans: Grandfathered health plans (those unchanged since the ACA) and short-term limited-duration health plans are exempt from the preventive services requirement. Verify with your insurer whether your plan is subject to the requirement.

Services not at the USPSTF A/B level: Not all screening tests are covered at no cost — only those with an ACIP, USPSTF A/B, or HRSA recommendation. If your provider recommends a test that is not on the covered list, standard cost-sharing applies.

Using the benefit effectively

Schedule your annual wellness visit with your primary care provider and request any overdue preventive screenings or vaccines at the same time. Confirm in advance that the provider is in-network and that the visit will be billed as a preventive care encounter. Keep a record of what you have received and what the USPSTF schedule recommends for your age, sex, and risk factors.

Comparing ACA-mandated preventive services by population

The no-cost preventive services benefit covers different services for different populations. The table below summarizes key services by group. This is not exhaustive — the full USPSTF list is maintained at uspreventiveservicestaskforce.org.

Population	Key services covered at no cost	Frequency
All adults	Blood pressure screening; depression screening; tobacco cessation counseling; alcohol misuse counseling; HIV screening (18–65); obesity counseling	Annual or as recommended
Adults 45+	Colorectal cancer screening (colonoscopy, stool tests, or CT colonography)	Every 1–10 years depending on method
Adults 50–80 (heavy smoking history)	Lung cancer screening (low-dose CT)	Annual
Women (all ages)	Contraception (all FDA-approved methods); domestic violence screening; folic acid supplementation (if planning pregnancy)	As needed
Women 21–65	Cervical cancer screening (Pap test ± HPV testing)	Every 3–5 years
Women 40–74	Breast cancer screening (mammogram)	Every 1–2 years depending on guidelines
Children (birth–17)	Well-child visits per Bright Futures schedule; developmental screening; vision and hearing; fluoride varnish	Per schedule
All ages	ACIP-recommended vaccines (influenza, COVID-19, Tdap, hepatitis, HPV, shingles, pneumococcal)	Per ACIP schedule

What this looks like in practice

Imagine you are a 46-year-old woman who recently enrolled in an ACA Marketplace plan. You have never had a colonoscopy. You schedule your annual wellness visit with your new primary care provider, who reviews your preventive care history and notes several services now due.

At the visit — billed as a preventive care encounter — your provider measures your blood pressure, reviews your depression screening questionnaire, and discusses your cardiovascular risk factors. She also notes that at age 46 you are now eligible for colorectal cancer screening under USPSTF guidance, recommends a mammogram, and confirms your influenza vaccine is overdue.

You schedule the mammogram at an in-network imaging center — covered at no cost. You receive the flu shot at the same visit — also no cost. For colorectal cancer screening, your provider refers you for a colonoscopy. You confirm with the endoscopy center that the procedure will be coded as a preventive screening. The facility and physician are both in-network. You pay nothing for the procedure itself.

At the same appointment, you mention you have been experiencing fatigue and would like your thyroid checked. Your provider explains that the thyroid test is not a USPSTF-mandated preventive screening — it will be billed as a diagnostic service and subject to your deductible. You decide to address it at a follow-up visit billed as a separate diagnostic encounter.

Step by step: scheduling no-cost preventive care

1. Identify what is due for your age, sex, and risk factors. Review the USPSTF recommendations for your population. Your insurer’s member portal may also offer a preventive care checklist personalized to your age and sex.

2. Find an in-network primary care provider. The no-cost benefit applies only when you see an in-network provider. Confirm network status before booking.

3. Schedule an annual wellness visit. Call or book online. When scheduling, confirm that the appointment type is a “wellness” or “preventive” visit. This tells the billing team how to code the visit from the start.

4. Request vaccines at the same visit. Vaccines administered during an in-network preventive visit are covered at no cost. Bring your vaccination record and ask which ACIP-recommended vaccines you are due for.

5. Separate any non-preventive concerns. If you have a new symptom or chronic condition to discuss, ask whether it can be addressed at a follow-up visit billed separately. Mixing preventive and diagnostic care at the same appointment can result in a portion of the visit triggering cost-sharing.

6. Confirm screening referral coding. If your provider refers you for a screening (mammogram, colonoscopy, lung CT), confirm with the specialist facility that the procedure will be billed as a preventive screening — not a diagnostic procedure — so cost-sharing does not apply.

7. Review your EOB. After the visit, review your Explanation of Benefits from your insurer. If cost-sharing has been applied to a service that should be no-cost, contact your insurer to appeal.

What to do if you are charged for a preventive service

Unexpected charges for preventive care are one of the most common patient billing complaints. If you receive a bill for a service you believe should have been covered at no cost, follow this process:

First, request the itemized bill from your provider and the explanation of benefits (EOB) from your insurer. The EOB will show how the visit was coded and why cost-sharing applied. Common reasons include: the visit was coded as a diagnostic visit rather than a preventive visit; you saw an out-of-network provider; your plan is grandfathered; or the specific service is not rated A or B by USPSTF.

If you believe the coding is incorrect — for example, your preventive visit was miscoded as a diagnostic encounter — contact your provider’s billing department first and ask them to review and resubmit the claim with the correct preventive care code. Provide documentation of the appointment type as agreed at scheduling.

If the insurer applies cost-sharing that you believe is not permissible under ACA Section 2713, file a formal appeal with your insurer. If the appeal is denied, contact your state insurance commissioner’s office or the HHS Office of Civil Rights, which enforces ACA preventive care requirements.

Men’s preventive care: commonly overlooked services

Men are statistically less likely to use preventive care, but ACA-compliant plans cover the same core preventive services for men as for women in categories where recommendations apply. Services commonly overlooked by male patients include:

Blood pressure screening: Recommended for all adults. High blood pressure often has no symptoms, and early detection allows for lifestyle or medication interventions before organ damage occurs.

Colorectal cancer screening: Recommended starting at age 45 for average-risk men. Men are somewhat more likely than women to develop colorectal cancer, making this screening particularly valuable.

Lung cancer screening: For men aged 50–80 who have a 20 pack-year or greater smoking history and currently smoke or have quit within the past 15 years, annual low-dose CT screening is recommended and covered at no cost.

Depression and alcohol misuse screening: These screenings are recommended for all adults and are covered during the annual wellness visit at no cost.

HIV screening: Recommended at least once for adults aged 15–65 and more frequently for those at higher risk.

Abdominal aortic aneurysm (AAA) screening: For men aged 65–75 who have ever smoked, a one-time abdominal ultrasound is recommended and covered at no cost. An AAA is a bulge in the aorta that can be life-threatening if it ruptures; one screening is sufficient for average-risk male smokers.

Requesting these services during your annual wellness visit ensures they are billed as preventive encounters covered at no cost. If your provider does not proactively offer a preventive screening that applies to you, ask about it by name.

Documents and terms you will see

When navigating preventive care at no cost, you will encounter these terms in plan documents and clinical settings.

• Preventive care — services aimed at preventing illness or detecting conditions early, before symptoms appear
• Deductible — the amount you pay before your insurance covers costs; preventive services are exempt and do not count toward deductible first
• Wellness visit — an annual checkup focused on preventive screening, health counseling, and vaccines rather than treating symptoms
• Colonoscopy — a screening procedure for colorectal cancer; covered at no cost as a preventive screening for eligible adults
• In-network — a provider or facility contracted with your plan; the no-cost benefit applies only at in-network providers
• Copay — a fixed amount due per visit; preventive care visits at in-network providers should carry a $0 copay under ACA rules