Preventive Care

Preventive care is the set of healthcare services that the ACA requires all Marketplace plans to cover at 100% with no cost-sharing, when you receive them from an in-network provider. That means no copay, no coinsurance, and no deductible. You pay nothing at the visit. Around 85 services qualify across three lists set by federal agencies.

The three lists

A service is “preventive” under the ACA only if it is on one of these lists:

• USPSTF Grade A or B recommendations (United States Preventive Services Task Force): cancer screenings, cholesterol, diabetes, HIV, depression, and more
• ACIP immunizations (Advisory Committee on Immunization Practices): the standard adult and childhood vaccine schedule
• HRSA women’s preventive guidelines (Health Resources and Services Administration): contraception, breastfeeding support, well-woman visits, pregnancy-related care
• HRSA Bright Futures for children: well-baby, well-child, developmental screenings, lead screening, autism screening

Common preventive services covered at $0

For adults:

• Annual physical / wellness visit
• Blood pressure, cholesterol, diabetes (type 2), and HIV screening
• Colorectal cancer screening (colonoscopy starting at 45)
• Mammograms (every 1-2 years starting at 40)
• Lung cancer screening for high-risk smokers
• Flu shot, COVID booster, shingles vaccine, Tdap, pneumococcal
• Depression screening, alcohol misuse screening, tobacco cessation counseling
• Statin medication for adults at high risk of cardiovascular disease (under specific USPSTF criteria)

For women specifically:

• Well-woman visit (annual)
• Pap smear / cervical cancer screening
• All FDA-approved contraceptive methods (at least one method in each category)
• Breastfeeding support, supplies, and counseling
• Prenatal visits, gestational diabetes screening, breastfeeding equipment
• Domestic violence screening and counseling
• BRCA genetic counseling (for women at increased risk)

For children:

• Well-baby and well-child visits (regular schedule from birth through age 21)
• All ACIP-recommended childhood immunizations
• Developmental, autism, and behavioral screenings
• Lead and tuberculosis screening (for at-risk children)
• Vision and hearing screening
• Fluoride varnish for infants and young children

Must be in-network

The $0 cost-sharing rule only applies when you see an in-network provider for a preventive service. If you go out-of-network, the plan can charge you. If a preventive visit turns into something else (the doctor finds a polyp during a screening colonoscopy and removes it, for example) the billing rules get more complex. Some of that follow-up care can be billed as diagnostic and subject to your deductible. Always confirm with your provider’s billing office before a procedure if you want to know what is preventive and what is not.

Example

A 50-year-old man in Texas with a Bronze plan and a $7,000 deductible visits his in-network primary care doctor for an annual checkup. The doctor orders a colonoscopy (his first, age-appropriate) and a cholesterol panel. The visit, the screening colonoscopy, and the labs are all $0 to him. He has not paid a dollar of his deductible, and yet none of these services cost him anything out of pocket.

Related terms

• Essential Health Benefits
• Deductible
• In-Network
• Qualified Health Plan

Run the calculator to find in-network preventive care providers in your county.