Preventive Care: What Can Be Covered Before You Get Sick?
Preventive care is one of the most valuable parts of health insurance — even if most people do not search for it until they need it. Under Affordable Care Act / Covered California health plans, many preventive services may be covered at no additional cost when you use an in-network provider and the service is billed as preventive care.
That can include routine checkups, vaccines, screening tests, women’s preventive services, certain cancer screenings, cholesterol and diabetes screening, and other services intended to catch problems early — before they become larger medical and financial problems.
Important billing warning: “Free preventive care” does not mean every doctor visit is free. If you go in for a preventive visit but also discuss symptoms, pain, a diagnosis, medication changes, or treatment for an existing condition, the appointment may be billed as a regular office visit. That can mean a copay, coinsurance, or deductible charge depending on your plan.
Questions This Page Answers
- What preventive care may be covered at no additional cost?
- Why might I still get a bill after a “free” preventive visit?
- How do vaccines, screenings, nutrition, and chronic disease prevention fit into Covered California plans?
- Where can I find related pages on diabetes, weight, nutrition, Medicare, and essential health benefits?
Preventive Care Is Not Just a Checkup
Preventive care can include screenings and counseling that help identify risks early. Examples may include blood pressure screening, cholesterol screening, diabetes screening, certain cancer screenings, immunizations, tobacco-use counseling, obesity screening, depression screening, and women’s preventive services.
For many people, the practical question is not just “Is preventive care covered?” The better question is: “What should I ask my doctor to code as preventive, and what should I expect might be billed as treatment?”
Nutrition, Weight, Diabetes & Chronic Disease Prevention
Insurance can help pay for covered preventive services, but your day-to-day health habits still matter. See our related page on Weight & Nutrition for food, exercise, wellness, and prevention resources.
If your concern is diabetes, cholesterol, blood pressure, obesity, heart disease, kidney disease, cancer screening, or another chronic condition, preventive care and disease management can overlap. A screening test may be preventive, while treatment after a diagnosis may be subject to your plan’s normal cost-sharing rules.
Related Health Insurance Topics
Essential Health Benefits: Preventive and wellness services are one of the ACA’s 10 essential health benefits. See our page on 10 Essential Health Benefits.
Metal Levels & Cost Sharing: If a service is not billed as preventive, your deductible, copay, coinsurance, and out-of-pocket maximum may matter. See Metal Levels – Platinum, Gold, Silver & Bronze.
Provider Networks: Preventive care is usually safest from a billing standpoint when you use an in-network doctor, clinic, lab, or medical group. See our Provider Finder resources.
Medicare Preventive Services: If you are on Medicare or turning 65, preventive care rules are different from Covered California rules. Start with our Medicare enrollment and coverage page.
Before Your Preventive Visit
- Confirm your doctor, facility, and lab are in-network.
- Ask whether the visit is being scheduled as a preventive visit, annual wellness visit, or problem-focused visit.
- Ask whether any lab work, screening, vaccine, or follow-up test may be billed separately.
- If you have symptoms or an existing diagnosis, ask whether the visit may be billed as treatment rather than prevention.
Need help comparing Covered California plans?
Preventive care is only one part of choosing a plan. Networks, doctors, prescriptions, deductibles, copays, subsidies, and total out-of-pocket exposure can matter more than the monthly premium alone.
Disclaimer: This page is general information only. Steve Shorr is not a medical doctor, attorney, or tax advisor. Always confirm coverage, provider network status, billing codes, and medical recommendations with your doctor, insurance company, or Covered California plan.
#ACA / ObamaCare Preventative Care & Wellness Programs
- Here’s a Plain English List! from HealthCare.Gov of preventative services you can get with NO DEDUCTIBLE.
- However, if Preventive care is given during an Office Visit or as an outpatient or vice versa Covered CA it might not be covered under the Preventative Care section of your policy Check with your doctor. Preventative Screenings and other services are covered with no deductible for adults and children with no current symptoms or history of a health problem. Specimen Policy Page 92
- If one has history or symptoms, then it’s covered under the diagnostic benefit Page 74 Subject to Co-Pays & the Deductible. Maintenance of a known problem, like those listed below as common risk factors, is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles. Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link. Annual physicals may not be a benefit LA Times 8.2.2016
- Ouch. That ‘Free’ Annual Checkup Might Cost You. Here’s Why
- Preventive care doctor visits are free, but if you bring up a health concern during the appointment, the visit may turn into a traditional doctor visit. That means you would have to pay a copay. The same could go for any tests that lead to more treatment or follow-up visits. Learn More Covered CA *
- Ways to get preventative care covered if doctor says yes, but Insurance Company says no. NPR.org *
- If one has history or symptoms, then it’s covered under the diagnostic benefit Page 74 Subject to Co-Pays & the Deductible. Maintenance of a known problem, like those listed below as common risk factors, is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles. Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link. Annual physicals may not be a benefit LA Times 8.2.2016
- Health Care Reform hopes to save premium dollars as 20% of Employee Health Care Spending is on these common risk factors: health net pulse.com/
- stress
- depression
- high blood pressure
- high cholesterol
- obesity
- excessive alcohol use
- tobacco use
- US Preventative Services Task Force – Consumer Information for tons of different problems
Resources & Links
- A federal appeals court in Texas on 6.21.2024 (read courts actual ruling) found unconstitutional a key component of the Affordable Care Act that grants a health task force the effective authority to require that insurers both cover an array of preventive health interventions and screenings and refrain from imposing out-of-pocket costs for them. NBC News *
- SCOTUS to review ACA preventive services mandate 1/11/2025
- Appeals Court Hears Appeal Over Obamacare’s Preventive Care Mandate KFF 3.5.2024
- The Texas ruling of March 30, 2023 (KFF Summary) * KFF update 4.7.2023 * doesn’t count in CA. Please don’t take blanket summaries & hype as gospel. Read the sources links
- California law that requires all health plans regulated by the State of California to cover the same necessary preventive services at no cost to the patient, consumers enrolled in plans offered through Covered California will continue to have access to these critical health care services without disruption. Covered CA Email dated 4.6.2023 * Joint Statement *
- FAQ finding doctors, labs and hospitals, when there’s confusion
Government Public Health Agencies
- CA Department of Public Health
- Centers for Disease Control & Prevention
- State of Israel – Very Detailed in English
- California State Disability Insurance
- Department of Industrial Relations – Paid Sick Leave
- World Health Organization
- World Meter Statistics
- US Department of Labor – Pandemic
- covid19.ca.gov
Social Service Agencies
All our Health plans are Guaranteed Issue with No Pre X Clause
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There is No charge for our complementary services, we are paid by the Insurance Company.
- Our Quote Engine Takes all the complexity out of using pencil and paper to figure out the premiums per the Obamacare/ACA rules under CFR §1.36B-3 *
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Trump Make American Healthy
#Nutrition & weight control
Visit our new & Updated webpage
Trump Make America Healthy Again
- RFK Jr.’s MAHA Movement Has Picked Up Steam in Statehouses. Here’s What To Expect in 2026 Kff.org January 2026
- The Supreme Court has determined that health insurance plans under the Affordable Care Act (ACA), also known as Obamacare, must continue to fully cover preventative services, including cancer screenings, HIV prevention medication, and mental health counseling, without co-pays or deductibles. Forbes *
- Nearly half of the U.S. population is pre-diabetic or has type-2 diabetes. Every month, diabetes causes 13,000 new amputations, 5,000 new cases of kidney failure and up to 2,000 new cases of blindness in our country. In 1960, approximately 13 percent of American adults were obese. Now, more than 40 percent of Americans are obese, and more than 70 percent are either obese or overweight.
- Even more shockingly, one-quarter of our teenagers today are pre-diabetic or have type-2 diabetes, and obesity is the leading medical reason that 71 percent of young Americans are disqualified from military service. Learn More >>> The Hill 11/2024 * Listing of the 6 Points Beckers Hospital Review 12/2024 *
Medicare Preventative Services
Medicare #Preventative Services & Wellness Visit Publication # 10110
Visit our main webpage on preventative services
More on Medicare Preventative Services
Video’s
- Preventative Benefits VIDEO
- Vaccines VIDEO
- Are All Vaccines Fully Covered by Medicare and Medicaid? NCOA.org *
- Why it’s harder to get COVID Vaccine Commonwealth Fund *
- Stroke Awareness Month VIDEO
- Heart Disease – Screenings under Part B
- Video on Glacoma
- Silver Sneakers
- Review your potential risk for depression and your level of safety.
- Offer to talk with you about creating advance directives, legal documents that allow you to put in writing what kind of health care you would want if you were too ill to speak for yourself.
- Learn more than you ever wanted to know about HRA – Health Risk Assessments
- Annual wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage READ MORE 42 CFR § 410.15
- Medicare Health Outcome Survey
- Medicare does not cover an annual physical exam – see 15 pages from Medicare to explain the difference. “It’s very important that someone, when they call to make an appointment, uses those magic words, ‘annual wellness visit,’”An annual physical typically involves an exam by a doctor along with bloodwork or other tests. The annual wellness visit generally doesn’t include a physical exam, except to check routine measurements such as height, weight and blood pressure. CA Healthline.org *
- Medicare & You: Flu Prevention VIDEO
- Health Risk Assessment
- Our Webpage on Preventative Care – Wellness Visit – Medicare
- JFK Inaugural Address
- President Kennedy – Help our country – Not just get free benefits
Ask Not, what your country can do for you
What can you do for your country - Medicare’s Preventative Benefits
- Kaiser VIDEO Play List
- Kaiser Thrive Little Miss Sunshine
See also programs that might be offered by Medi Gap or Medicare Advantage Carriers
- Medi Gap – Supplement Plans
- Medicare Advantage Plans – Part C
Mammogram, Bone Density & Osteoporosis
Blue Shield of California Authorized Agent - Broker
Preventative Care
Bone Density Osteoporosis
Medicare covers bone mass measurements to see if you’re at risk for broken bones due to osteoporosis. Osteoporosis is a disease in which your bones become weak and brittle. In general, the lower your bone density, the higher your risk for a fracture.
Medicare Coverage of #Cancer Treatment Publication # 11931
- Our FAQ Cancer Experimental Rx
- 15 Cancer Symptoms WebMd.com *
- Some early forms of breast cancer may not need treatment Study says Time.com *
- Visit our webpage on cancer
Resources & Links
MLN Medicare Preventive Services for Professionals
- Medline Plus Trusted Health Information
- Merck Manual – Home Edition
- health.gov/my health finder
Vision
How often are Eye exams covered?
Medicare doesn’t cover routine eye exams (sometimes called “eye refractions”) for eyeglasses or contact lenses. Medicare Part B (Medical Insurance) covers some preventive and diagnostic eye exams:
- Yearly eye exam
- Glaucoma tests
- Macular degeneration
- Medicare Part B (Medical Insurance) covers a yearly eye exam for diabetic retinopathy
- ICD 10
- Web MD
by an eye doctor who’s legally allowed to do the test in your state.
Who’s eligible?
All people with Part B who have diabetes are covered.
Your costs in Original Medicare
You pay 20% of the Medicare-approved amount for the doctor’s services, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.
Note
To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service. medicare.gov yearly-eye-exam
- cms.gov/VisionServices_FactSheet
- FAQs / Ask Us a Question
- ICD billing codes
- 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
- 92083 — extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus programs G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).
- 92083 — extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus programs G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).
Dental For #Everyone,
has an excellent website with full brochures, Instant online quoting and enrollment
- Dental for Everyone includes quotes from
- Careington Discount Plan
- Bright Benefits
- Renaissance Dental
- Delta Dental
- AmFirst - but not the special one for share of cost with premium to $425
- One of our colleagues on how Dental for Everyone Works.
- Some of our webpages on dental
- VSP Vision
See prior and HISTORICAL versions of this page on Archive.org
https://www.commonwealthfund.org/blog/2026/kids-lose-when-vaccine-coverage-rules-are-unclear