Resources · Coverage Basics
Does health insurance cover preventive care? Colonoscopy, mammograms and physicals, on and off the Marketplace
The short answer
All Marketplace health plans, and many other plans, must cover a federal list of preventive services without charging a copay or coinsurance, even if you have not met your deductible. The list includes colorectal cancer screening for adults 45 to 75 and a screening mammogram every one to two years for women 40 and older (HealthCare.gov, preventive care for adults; for women). Two conditions matter: the provider generally has to be in network, and HealthCare.gov itself says "$0 cost isn't guaranteed in all cases" (HealthCare.gov, preventive health services).
Plans that are not ACA major medical, such as short-term plans, fixed indemnity policies and health sharing programs, do not have to follow that list. If preventive care matters to you, the first question about any plan is which kind it is.
What the preventive care rule covers
HealthCare.gov publishes three lists: adults, women and children. A few of the items people ask about most:
| Service | Who it is listed for | Source |
|---|---|---|
| Colorectal cancer screening | Adults 45 to 75 | Adults list |
| Screening mammogram | Women 40 and older, every 1 to 2 years | Women list |
| Cervical cancer screening (Pap test) | Women 21 to 65 | Women list |
| Well-woman visits | All women | Women list |
| Blood pressure screening | Adults | Adults list |
| Cholesterol screening | Adults of certain ages or at higher risk | Adults list |
| Type 2 diabetes screening | Adults 40 to 70 who are overweight or obese | Adults list |
| Immunizations, including flu and shingles | Adults; doses and ages vary | Adults list |
On those plans, these are covered "without charging you a copayment or coinsurance. This is true even if you haven't met your yearly deductible" (HealthCare.gov). The deductible is defined the same way: what you pay before the plan pays, "except free preventive services" (same page).
Colonoscopy: what to ask before you book
Colorectal cancer screening is on the adult list for ages 45 to 75. The questions people raise on review calls are about everything around the screening:
- Is this a screening or a diagnostic colonoscopy? The list covers screening. If you have symptoms, or the test is to follow up on something already found, ask your plan how it will be billed.
- What if they remove a polyp? Ask the plan, before the procedure, how it handles a screening colonoscopy that turns into polyp removal.
- Anesthesia and the facility. A colonoscopy has several bills: the doctor, the facility, anesthesia and any lab work. Ask whether each provider is in network.
- After a positive stool test. If you screened with a home stool test and it came back positive, ask the plan how it covers the follow-up colonoscopy.
We are not giving you the answers to those questions here because they depend on the plan's documents. Get them from the plan in writing.
Mammograms
A screening mammogram, with or without a clinical breast exam, is on the women's list every one to two years from age 40 (HealthCare.gov). A mammogram ordered to look at a lump or a symptom is diagnostic, not screening, and may go through your deductible and coinsurance. Ask which one you are being scheduled for.
Does a physical count toward my out-of-pocket max?
The adult list is a list of services, not a single "annual physical." For women, well-woman visits are on the list. Covered preventive services at no cost do not generate a bill to count. But a checkup can include more than prevention: if the doctor treats or investigates a problem during the same visit, that part can be billed under your deductible and coinsurance, and those payments count toward your out-of-pocket maximum. HealthCare.gov's own caution, "$0 cost isn't guaranteed in all cases," applies (HealthCare.gov).
How the deductible, coinsurance and out-of-pocket maximum work in a real year is laid out in deductible, copay, coinsurance and out-of-pocket max, with examples.
What about blood work?
Some lab screenings are on the list for certain people, such as cholesterol screening for adults of certain ages or at higher risk, and type 2 diabetes screening for adults 40 to 70 who are overweight or obese (HealthCare.gov). Other lab work your doctor orders may be billed normally. Before a blood draw, ask whether each test is being billed as preventive, and whether the lab is in network.
Preventive care on plans outside the Marketplace
"Outside the Marketplace" covers very different products. What happens to your checkup depends on which one you have.
| Plan type | Does it have to cover the preventive care list at $0? |
|---|---|
| Marketplace plan | Yes. "All Marketplace health plans" must (HealthCare.gov). |
| Other ACA major medical, including many plans sold off the Marketplace and job-based plans | HealthCare.gov says "many other plans" must. Ask the plan whether it follows the ACA preventive care rules. |
| Short-term, limited-duration insurance | No. It is not subject to the ACA's rules for individual coverage (CMS); preventive care is commonly limited or absent. |
| Fixed indemnity | No. It pays a set amount per event, for example "$50 per medical exam" in CMS's individual-market example, whatever the exam costs (CMS). |
| Health care sharing | Not insurance. CMS says these programs "generally are not health insurance plans or coverage" (CMS). What is shared follows the program's guidelines. |
If a plan you are considering is not ACA major medical, ask for its written list of what it pays for a routine visit, a colonoscopy and a mammogram, and budget for the rest. What a fixed benefit pays against a real bill is shown in hospital indemnity insurance vs major medical. If you are comparing these paths side by side, see private health insurance vs Obamacare.
Five questions to ask any plan
- Is this plan subject to the ACA preventive care requirements?
- Which of my providers are in network for preventive visits, labs and imaging?
- How do you bill a screening colonoscopy if a polyp is removed, and a colonoscopy after a positive stool test?
- Is my mammogram being scheduled as screening or diagnostic?
- If my doctor addresses a health problem during a checkup, how is that part billed?
Our guide to checking your doctor, hospital and prescriptions before you buy shows how to confirm the network part.
How AFHC handles this
America First Healthcare is an independent licensed agency. In a free 15-minute review, a licensed advisor tells you which category each plan you are considering is in, ACA major medical or not, and what that means for your checkups and screenings. If a plan does not cover preventive care the way a Marketplace plan does, we say so before you buy. Start with a free healthcare review. To see what clients say about working with us, including the critical reviews, read America First Healthcare reviews.
Frequently asked questions
Is a colonoscopy covered by health insurance?
On Marketplace plans and many other plans, colorectal cancer screening for adults 45 to 75 is a preventive service covered without a copay or coinsurance in network, even before the deductible, according to HealthCare.gov. A diagnostic colonoscopy, or extra services during the procedure, may be billed differently. Ask your plan in writing.
Are mammograms free with insurance?
On Marketplace plans and many other plans, a screening mammogram every one to two years for women 40 and older is covered without a copay or coinsurance in network, according to HealthCare.gov. A diagnostic mammogram, ordered because of a symptom, may go through your deductible.
Does my physical count toward my deductible or out-of-pocket max?
Covered preventive services at no cost do not create a bill to count. If your doctor treats or investigates a problem during the visit, that part can be billed under your deductible and coinsurance, and those payments count toward your out-of-pocket maximum.
Do short-term health plans cover preventive care?
They do not have to. Short-term, limited-duration insurance is not subject to the ACA's rules for individual coverage, so preventive care is commonly limited or absent. Read the policy's exclusions before you buy.
Is preventive care covered before I meet my deductible?
On Marketplace plans and many other plans, yes: listed preventive services are covered without a copay or coinsurance even if you have not met your deductible, when you use an in-network provider. HealthCare.gov notes that $0 cost is not guaranteed in all cases.
Sources
- HealthCare.gov, Preventive health services, Preventive care benefits for adults and for women
- CMS, Short-term, limited-duration insurance and independent, noncoordinated excepted benefits coverage fact sheet
- CMS, What is considered health insurance
Educational only, not medical, legal or personalized insurance advice.