Plan type, not state, decides if preventive care is free

What decides whether preventive care is free in the US?

Longetic holds the record of what you have already had done, which is where this question usually starts. In the United States three things decide whether a preventive service costs you nothing: whether your plan is non-grandfathered, whether it is fully insured or self funded, and whether the specific service sits on a current federal list. Your state matters for only one of the three.

This page is about the United States. The rules below come from the Affordable Care Act, from federal insurance regulation and from state insurance codes, and they have no European equivalent. If you are reading from Europe, the answer to the same question lives with your national health service or your insurer, not here.

The federal rule itself is short. 45 CFR 147.130 requires non-grandfathered plans to cover a defined set of preventive services with no copayment, no coinsurance and no deductible. What the rule does not do is reach every plan equally, and that is the part almost nobody explains. HealthCare.gov lists the covered services and then says only that the requirement applies to Marketplace plans and to "many other plans", with the caveat that "$0 cost isn't guaranteed in all cases". Which other plans, and why not guaranteed, is the whole question.

So start with what kind of plan you have. The table below is the map.

The third row is the one that surprises people, and it is not a rare case. In the 2025 KFF Employer Health Benefits Survey, 67 percent of covered workers were in plans that are self funded, meaning the employer pays the claims and buys administration rather than insurance. Those plans still owe the federal preventive list. They are simply out of reach of anything a state legislature does, because the deemer clause of 29 U.S.C. 1144 says such a plan is not to be "deemed to be an insurance company or other insurer" for the purposes of state insurance law.

Why does the same screening cost nothing for one person and hundreds for another?

Four things move the price, and none of them is the test itself. Whether the plan is grandfathered, whether the provider is in network, whether the service matches the recommendation in force for your age, sex and risk, and how the visit was coded. Two people with the same blood draw can get different bills for any one of those reasons.

The network rule is the one that catches most people. The federal requirement is generally an in-network obligation, so the same service from an out-of-network provider can carry full cost sharing, with a narrow exception where the plan has no in-network provider able to deliver it. Checking the network before the appointment costs nothing and is the single highest-yield thing on this page.

Being on the list is also narrower than it sounds. A service qualifies for you only if the recommendation in force covers your age, sex and risk profile. A cholesterol panel ordered because you asked for one is not the same billing event as a cholesterol panel ordered under a screening recommendation that applies to you, even though the laboratory does identical work. Our guide to what a standard annual physical actually includes covers which checks are routine in the first place.

The fourth reason is billing. A plan may charge for the office visit itself when the preventive service is billed separately, or when the visit was primarily about something else, so raising a new symptom during a screening appointment can change how the whole encounter is coded. That is a separate question from whether the service was covered at all.

Does your state have its own preventive coverage law?

Some states do, and it changes less than it sounds. A state insurance law reaches fully insured plans sold in that state and cannot reach a self funded employer plan, because federal law preempts it. New York, Illinois and New Jersey have their own requirements written into state law, while Texas publishes none and points residents to the federal rule instead.

Four states, four different answers. These are examples rather than a survey, and the point of the table is the last column, which reads the same for every row.

New York codifies the requirement in its Insurance Law, and its regulator has said plainly that the state obligation stands on its own feet: Circular Letter No. 5 (2025) says that, "no matter any change in ACIP recommendations", issuers must still cover COVID-19 immunizations for children through age 18 without cost-sharing. Illinois carries the requirement in 50 Ill. Adm. Code 2001.8 and added state-set vaccine guidance in December 2025, which its Department of Insurance spells out along with the list of plans it does not reach. New Jersey covers all four federal categories in N.J.S.A. 26:2J-4.45.

Texas is the honest counterexample. The Texas Department of Insurance tells residents that "Federal law requires most health plans to cover a range of preventive services" and points them at HealthCare.gov, with no state statute behind it. Living in Texas does not make preventive care less free today. It means there is no second layer if the federal one moves.

That second layer is being built in more places than it used to be. The Commonwealth Fund counted at least 15 states with broad ACA-style requirements in their individual markets back in 2022. More recently, KFF reports that thirteen states have moved to require state-regulated insurers to cover COVID-19 vaccines at no cost, four of them for every vaccine the state recommends, and Georgetown's Center on Health Insurance Reforms documents states such as Colorado giving their insurance commissioners standing authority to adopt state clinical guidance if federal standards are rolled back.

What is on the no-cost list, and did anything change in 2026?

Four categories, set by federal regulation: A and B rated services from the US Preventive Services Task Force, immunizations recommended by ACIP, and two sets of guidelines supported by HRSA, one for children and one for women. Nothing new was added to the Task Force list during 2026, and one women's guideline was updated, taking effect for most plans in 2027. A revised CDC childhood immunization schedule from January 2026 was stayed by a federal court in March.

The four categories are set out at 45 CFR 147.130(a)(1). They are evidence-based items or services rated A or B by the US Preventive Services Task Force, immunizations for routine use recommended by the Advisory Committee on Immunization Practices, HRSA-supported guidelines for infants, children and adolescents, and HRSA-supported additional preventive care and screenings for women.

New additions are slow by design. Under 45 CFR 147.130(b)(1), a plan owes a new recommendation only "for plan years ... that begin on or after the date that is one year after the date the recommendation or guideline is issued". A recommendation you read about in the news is usually more than a year away from your bill.

Two concrete facts for 2026, both checkable in a minute. First, the Task Force published no new final A or B recommendation at any point in 2026. The most recent entry on its own A and B list is screening for intimate partner violence in women of reproductive age, grade B, from June 2025. Second, HRSA did update one women's guideline: on 29 December 2025 the Administrator accepted a revised cervical cancer screening recommendation, published in the Federal Register on 5 January 2026. It states that patient-collected hrHPV testing "is an appropriate method and should be offered as an option for cervical cancer screening in women aged 30 to 65 years at average risk". That notice also says the coverage requirement attaches for plan years beginning one year later, so "for most plans, this update will take effect ... in 2027".

The immunization category is the one that moved in 2026. According to the Congressional Research Service, the CDC revised the childhood immunization schedule on 5 January 2026, a federal district court stayed that revision on 16 March 2026, which returned the schedule to its May 2025 version, and the ruling was appealed on 29 April 2026.

Did the Supreme Court change any of this?

The rule survived, and the reason it survived is the part worth knowing. In June 2025 the Supreme Court upheld the appointment of Task Force members, so their A and B ratings still trigger no-cost coverage. It did so by finding that the Health and Human Services Secretary can remove members at will and can block a recommendation before it takes effect.

The case is Kennedy v. Braidwood Management, decided on 27 June 2025 by six votes to three. The holding is narrow: "Task Force members are inferior officers whose appointment by the Secretary of HHS is consistent with the Appointments Clause." The coverage mechanism itself was never what the case turned on, and the Court restated it plainly: the Act mandates no-cost coverage of "evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations" of the Task Force.

The reasoning is what a reader should take away. The appointments survived because the Court found the Task Force is supervised: the Secretary's power to remove members at will is, in the Court's words, a "powerful tool for control", and the Secretary "has statutory authority to directly review and block Task Force recommendations before they take effect". The same finding that kept the requirement standing also confirms that a future recommendation can be stopped before it ever reaches your plan. That is the practical reason a state-law layer is worth knowing about, and the practical reason to check what your own plan says rather than what the national list says.

How do you find out what your own plan covers?

Start with two questions your plan documents answer: is the plan grandfathered, and is it self funded. The Summary of Benefits and Coverage names the plan and its cost sharing, and the plan administrator can confirm how it is funded. If it is fully insured, your state insurance department is the second place to look.

Those two answers settle which of the five rows above you are in, and everything else follows from that. If the plan is self funded, your state insurance department cannot help you and there is no point calling it. If it is fully insured, the department is exactly the right place to ask whether your state adds anything on top.

There is a third question, and it is the one no plan document answers: which of these services have you already had, and when. Coverage is annual or multi-year for most screenings, so the practical question is rarely "is it free" and usually "am I due". A claims history tells you only what your current insurer paid for. It misses anything you paid for yourself, anything from a previous employer's plan, and anything done abroad. If you have a chronic diagnosis this gets harder rather than easier, because the checks a chronic diagnosis adds to your schedule tend to be spread across several specialists.

No single tool answers all three questions, and the table below is an honest account of which one answers which. As a disclosure, Longetic is our product, so weigh this accordingly: it holds the record of what you have had done and it does not know anything at all about your coverage. Our free screening tool maps age, sex and risk factors against published screening guidelines, which is what is generally recommended, not what your plan pays for.

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