Preventive Care Most Health Insurance Plans Must Cover at No Cost

What the law requires

The Affordable Care Act (ACA) requires most private health insurance plans to cover a set of preventive services without charging a copay, coinsurance, or deductible, even if a patient has not met their annual deductible yet. This applies to non-grandfathered plans, meaning plans that were created or significantly changed after March 23, 2010.

The covered services are drawn from recommendations by three bodies: the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), and the Health Resources and Services Administration (HRSA). When one of these bodies issues an A or B rating for a service, plans subject to the ACA must cover it without cost-sharing.

Grandfathered plans (those that existed before the ACA and have not made major changes since) are exempt from this requirement. Medicaid and Medicare have separate, related rules. Always confirm coverage details directly with your insurer before scheduling a service.

This article is general health and insurance information, not medical or legal advice. Speak with a licensed healthcare provider or insurance professional for guidance specific to your situation.

Services commonly covered for adults

For adults, plans typically must cover blood pressure screening, cholesterol screening, colorectal cancer screening, lung cancer screening (for adults who meet specific smoking history criteria), and type 2 diabetes screening for adults with high blood pressure. Screenings for depression and alcohol misuse also appear on the list.

Mammograms and cervical cancer screenings (Pap smears and, where recommended, HPV tests) are covered for women at standard intervals. Sexually transmitted infection counseling and HIV screening are included as well.

Approved immunizations for adults include seasonal influenza, Tdap (tetanus, diphtheria, pertussis), shingles, pneumococcal, and others as recommended by ACIP. The specific vaccines covered and their schedules can change when ACIP updates its guidance.

For a broader list of screenings to discuss with your provider, see recommended health screenings for adults and children.

Services commonly covered for children and pregnant women

Well-child visits, which include developmental assessments, vision and hearing screening, and age-appropriate immunizations, are covered from birth through adolescence. HRSA's Bright Futures guidelines define the schedule most plans follow.

Screenings for autism, behavioral issues, lead exposure, and obesity are also on the list for children at recommended ages. Fluoride supplements and dental fluoride varnish are covered for young children whose water supply is low in fluoride.

For pregnant women, plans must cover prenatal folic acid supplementation, gestational diabetes screening, anemia screening, and depression screening. Breastfeeding counseling and equipment (such as a breast pump) are also covered under HRSA guidelines, though the specific equipment and timing can vary by plan.

If your family uses a community health center, those facilities are also required to offer preventive services on a sliding-fee basis. See how community health centers work for eligibility details.

Pregnant women, children, and individuals with chronic conditions should consult a qualified healthcare provider rather than relying on general guidance.

When cost-sharing can still apply

Coverage without cost-sharing applies only when the service is delivered for preventive purposes. If a colonoscopy begins as a screening but a polyp is removed during the same visit, some plans bill the procedure as diagnostic, which can trigger cost-sharing. This has been a common source of surprise bills. Reviewing your plan's explanation of benefits and asking your provider to code the visit correctly before it happens can help avoid this.

Cost-sharing can also apply if the preventive service is delivered by an out-of-network provider. The no-cost rule generally requires using in-network providers.

If your plan charges a cost-share for a service you believe should be free, file an appeal with your insurer. The appeal process and your rights are explained in the summary plan description every insurer must provide.

Understanding how deductibles and cost-sharing interact with these benefits is part of managing overall family healthcare costs. The guide to health insurance fundamentals covers those terms in plain language. Pairing preventive care with a tax-advantaged account is another way families reduce costs; see how FSAs and HSAs work for details.