The Screenings Your Plan Has to Cover for Free
A defined list of preventive services must be covered by most plans with no copay, no coinsurance and no deductible, when delivered in-network. It is one of the few unambiguously good deals in American health insurance, and it is underused mostly because people do not know what is on the list.
Roughly what is covered, by age
| Age | Commonly covered at no cost |
|---|---|
| All adults | Blood pressure, depression screening, HIV screening, immunizations, tobacco and alcohol counseling, obesity counseling |
| 18-39 | Cholesterol with risk factors, STI screening and counseling, cervical cancer screening from 21 |
| 40-49 | Diabetes screening, mammography discussion and screening in the recommended range, cholesterol |
| 45+ | Colorectal cancer screening — the recommended start age moved from 50 to 45 |
| 50-64 | Colorectal, mammography, lung cancer screening with qualifying smoking history, shingles and pneumococcal vaccines |
| 65+ | Bone density, aneurysm screening for some men with smoking history, annual wellness visit |
The list is set by recommendations from the US Preventive Services Task Force, the immunization advisory committee, and women's and children's health guidelines, and it is periodically updated. Both the ranges and the list itself move, so treat this as orientation rather than a legal citation.
The screening-to-diagnostic line is where the bills come from. A screening colonoscopy in an average-risk person is preventive. The same procedure done because of symptoms, or as follow-up to a positive stool test, has historically been billed as diagnostic — rules have improved on the follow-up point specifically, but the general principle stands. Ask before the procedure: "Will this be billed as screening or diagnostic, and what changes that?"
What is not free even during a preventive visit
- Anything out-of-network.
- Labs beyond the recommended screening set.
- The office visit portion if you raise a new problem.
- Follow-up on an abnormal finding.
- Screenings outside the recommended age or risk criteria, even if reasonable to do.
Getting the benefit
Ask your doctor which screenings you are due for by name. Confirm the facility and any lab are in-network. Ask how the visit will be coded. And check the EOB afterward — a preventive service that came back with patient responsibility is worth one phone call, and miscoding is common enough that the call frequently works.
Frequently Asked Questions
Does this apply to every plan?
Most ACA-regulated plans. Grandfathered plans and some short-term or non-compliant products are exempt, which is one of several reasons short-term plans are a poor substitute for real coverage.
Why was I billed for a screening?
Usually coding — diagnostic rather than screening — or an out-of-network lab. Both are worth appealing.
Is the annual physical itself free?
The preventive wellness visit is. Anything diagnostic that happens during it is not.
Do these recommendations change?
Yes, periodically, as evidence accumulates. Colorectal screening moving to 45 is a recent example.
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