Preventive Care: What's Free and What's Not

Thanks to the Affordable Care Act, health insurers in the U.S. have to cover preventive health care without requiring you to pay a deductible, copayment, or coinsurance. That rule applies to all non-grandfathered plans.

A pregnant woman discussing results with doctor
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So, what exactly counts as preventive care? Here’s the list of preventive care services for adults that, if recommended for you by your physician, must be provided free of cost-sharing. Children have a different list, and there's also an additional list of fully covered preventive services for women. As long as your health plan isn't grandfathered, any services on those lists will be fully covered by your plan, regardless of whether you've met your deductible.

Covered preventive care includes:

Cancer prevention measures:

  • Colorectal cancer related: for adults age 50 to 75, including screening colonoscopies, removal of polyps discovered during a screening colonoscopy, and anesthesia services required to perform the screening colonoscopy. Note that it's common, however, for patients to be charged cost-sharing if polyps are removed, or for future colonoscopies after polyps have been discovered in a previous test. And if the colonoscopy is being done in conjunction with any sort of symptoms, it will be considered diagnostic rather than preventive, which means regular cost-sharing rules would apply. It's a good idea to thoroughly discuss colonoscopy coverage with your health insurer in order to make sure you fully understand what is and isn't covered under the screening guidelines.
  • Breast cancer related: including screening mammograms every 1-2 years for women over 40, BRCA genetic testing and counseling for women at high risk, and breast cancer chemoprevention counseling for women at high risk.
  • Cervical cancer related: screening covered once every three years from ages 21 through 65; human papillomavirus DNA testing can instead be done in conjunction with a pap test once every five years.
  • Lung cancer related: screening for smokers or those who’ve quit smoking within the last 15 years and are between the ages of 55 and 80

Infectious disease prevention measures:

  • Hepatitis C screening one time for anyone born 1945-1965 and for any adult at high risk
  • Hepatitis B screening for pregnant women at their first prenatal visit, and for any adults considered at high risk.
  • HIV screening for anyone between ages 15-65, and for others at high risk
  • Syphilis screening for adults at high risk and all pregnant women
  • Chlamydia screening for young women and women at high risk
  • Gonorrhea screening for women at high risk
  • Sexually transmitted infection prevention counseling for adults at increased risk
    • Routine immunizations for adults as recommended by age for
      Hepatitis A.
    • Hepatitis B.
    • Herpes Zoster(shingles).
    • Human Papillomavirus.
    • Influenza (flu).
    • Measles, Mumps, Rubella.
    • Meningococcal.
    • Pneumococcal.
    • Tetanus, Diphtheria, Pertussis (lock-jaw and whooping cough).
    • Varicella (chickenpox).

Obesity screening and counseling.

Diet counseling for adults at high risk for chronic disease.

Recommended cardiovascular disease-related preventive measures:

  • Cholesterol screening for high-risk adults and adults of certain ages
  • Blood pressure screening
  • Diabetes type 2 screening for overweight adults age 40 to 70
  • Abdominal Aortic Aneurysm screening one time for men who have ever smoked
  • Aspirin when prescribed for cardiovascular disease prevention for high-risk adults between the ages of 50 and 59

Recommended substance abuse prevention measures:

  • Alcohol misuse screening and counseling
  • Tobacco use screening and cessation intervention for tobacco users

Depression screening.

Domestic violence and interpersonal violence screening and counseling for all women.

Osteoporosis screening for women over 60 based on risk factors.

Well-woman visits for women under 65.

Contraception for women with reproductive capacity as prescribed by a health care provider. Doesn’t include abortifacient drugs, doesn’t apply to health plans sponsored by exempt religious employers.

Preventive services for pregnant or nursing women:

  • Anemia screening
  • Breastfeeding support and counseling including supplies
  • Folic acid supplements for pregnant women and those who may become pregnant
  • Gestational diabetes screening at 24 and 28 weeks gestation and those at high risk
  • Hepatitis B screening at first prenatal visit
  • Rh incompatibility screening for all pregnant women and follow up screening if at increased risk
  • Expanded tobacco counseling
  • Urinary tract or other infection screening
  • Syphilis screening

Why Preventive Care Isn’t Free

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. 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.

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 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.

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), but it's currently under review by USPSTF, so it's possible that the recommendation could change in the future.

It's also important to understand that when you go to your doctor for preventive care, they might provide other services that aren't covered under the free preventive care benefit. For example, if your doctor 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. If in doubt, talk with your insurer beforehand so that you'll understand how your preventive care benefits work before the bill arrives.

Preventive Care Related to COVID-19

The COVID-19 pandemic is gripping the world in 2020. Although there's a lengthy process involved with adding covered preventive services through the channels described above, Congress quickly took action to ensure that most health insurance plans would fully cover the cost of COVID-19 testing. There is not yet a vaccine available, but once there is, that will almost certainly be added to the list of fully covered 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 have opted to go beyond the basic requirements, offering to fully cover COVID-19 treatment, as well as testing. Those provisions don't apply to self-insured plans unless the employer opts to waive cost-sharing for treatment, so it's important to reach out to your health plan to see exactly how COVID-19 costs are being handled.

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 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.

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

  2. Kennelly, Ryan. iHealthAgents. I Am Due For a Colonoscopy. Is it Covered? April 2020.

  3. Health Resources and Services Administration. Women's Preventive Services Guidelines. December 17, 2019.

  4. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Updated July 19, 2019.

  5. U.S. Preventive Services Task Force. Final Recommendation Statement: Prostate Cancer: Screening. Updated October 2018.

  6. U.S. Preventive Services Task Force. Draft Update Summary: Vitamin D Deficiency in Adults: Screening. Updated January 2019.

  7. Pollitz, Karen. Kaiser Family Foundation. Private Health Coverage of COVID-19: Key Facts and Issues. March 18, 2020.

  8. America's Health Insurance Plans. Health Insurance Providers Respond to Coronavirus (COVID-19). April 17, 2020.