Preventive care for adults: what is covered at $0

ACA plans, including every plan on Connect for Health Colorado, must cover a defined list of preventive services for adults with no copay, coinsurance or deductible when you use an in-network provider (HealthCare.gov, 2026, healthcare.gov/preventive-care-adults). The list is not a vague promise of a yearly checkup. It is built from three federal sources: services rated A or B by the U.S. Preventive Services Task Force (USPSTF), vaccines recommended by the CDC's immunization advisory committee (ACIP), and women's preventive guidelines supported by the Health Resources and Services Administration (HRSA). Each comes with ages and intervals, such as colorectal cancer screening from 45 to 75 and blood pressure checks every year from age 40. Colorado writes the USPSTF part into state law as well. This guide lists what is covered, when, and the coding rules that decide whether a visit stays at $0.

Who decides what counts as preventive

Federal law requires most health plans to cover, without cost sharing, services with an A or B rating from the USPSTF, adult immunizations recommended by ACIP and adopted by the CDC, and preventive care and screenings for women in comprehensive guidelines supported by HRSA (CMS and Departments, FAQs about ACA Implementation Part 51, January 10, 2022, cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-51.pdf). Where a recommendation does not specify frequency, method or setting, a plan may use reasonable medical management to set those details, which is why two plans can handle the same screening slightly differently.

The legal footing was tested in court. On June 27, 2025, the U.S. Supreme Court decided Kennedy v. Braidwood Management, holding that Task Force members are inferior officers properly appointed by the Secretary of Health and Human Services (Supreme Court of the United States, June 27, 2025, supremecourt.gov/opinions/24pdf/24-316_869d.pdf). The no-cost coverage requirement for A and B services therefore stayed in place.

Colorado adds its own layer. Under section 10-16-104(18), C.R.S., state-regulated health plans must cover preventive services that follow the Task Force's A or B recommendations, and that coverage is not subject to deductibles, copayments or coinsurance. SB21-016, signed July 6, 2021, added prevention services and screening for sexually transmitted infections for all covered persons regardless of gender, and required coverage for the total cost of contraception without cost sharing (Colorado General Assembly, SB21-016 signed act, 2021, leg.colorado.gov/sites/default/files/2021a_016_signed.pdf). Self-funded employer plans follow the federal rule rather than Colorado's statute.

Is a yearly physical required to be $0?

This is the most common misunderstanding about preventive care, so it is worth being precise. The federal adult preventive list on HealthCare.gov covers specific screenings, preventive services and vaccines; it does not list a general annual physical for every adult (HealthCare.gov, 2026, healthcare.gov/preventive-care-adults). What the federal guidelines do require is a well-woman visit: the HRSA-supported Women's Preventive Services Guidelines recommend at least one preventive care visit per year beginning in adolescence and continuing across the lifespan (Women's Preventive Services Initiative, 2022, womenspreventivehealth.org/recommendations/well-woman-preventive-visits). Well-child visits are also required for children.

"Annual Wellness Visit" is a Medicare term. Medicare Part B covers a yearly Wellness visit once every 12 months to build a prevention plan, and Medicare itself says it is not a routine physical exam (Medicare.gov, 2026, medicare.gov/coverage/yearly-wellness-visits). That benefit does not carry over to ACA plans for people under 65.

In practice, many adults get their screenings during a yearly visit with a primary care provider, and some plans cover an adult preventive exam as a plan benefit. Whether a general adult physical is $0 depends on the plan, so check the preventive row of the Summary of Benefits and Coverage. Colorado Option plans make the question smaller: gold and silver cover primary care visits at $0 with no visit limit, even when the visit is for an illness, and bronze covers the first three primary care visits at $0 (Colorado Regulation 4-2-81, Appendix A, 2026, doi.colorado.gov/sites/doi/files/documents/Amended%20Regulation%204-2-81%20Concerning%20Colorado%20Option%20Standardized%20Health%20Benefit%20Plans_0.pdf).

Adult screenings by age, with intervals

The table lists the USPSTF A and B recommendations most adults ask about, with the population and interval the Task Force gives (USPSTF A and B recommendations, 2026, uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations). Some intervals come from the Task Force's practice considerations: annual blood pressure screening from age 40 or with higher risk, and every 3 to 5 years from 18 to 39 after a normal reading (USPSTF, 2021, uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening); and diabetes screening every 3 years as a reasonable approach when blood glucose is normal (USPSTF, 2021, uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes).

Cancer screening details that change what you pay

Colorectal cancer screening has several covered test options, each with its own interval: a high-sensitivity stool test (gFOBT or FIT) every year, a stool DNA-FIT test every 1 to 3 years, CT colonography every 5 years, flexible sigmoidoscopy every 5 years (or every 10 years with a yearly FIT), or colonoscopy every 10 years. For adults 76 to 85, the Task Force gives a C grade and says screening should be offered selectively (USPSTF, 2021, uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening).

A screening colonoscopy covers more than the procedure. Federal guidance says plans may not charge cost sharing for items and services that are an integral part of it: a required specialist consultation beforehand, the bowel preparation medication, anesthesia, removal of a polyp during the screening, and the pathology exam on that polyp. And if a stool test or a direct visualization test comes back positive, the follow-up colonoscopy must also be covered with no cost sharing, because the Task Force treats it as part of completing the screening (FAQs about ACA Implementation Part 51, January 10, 2022, cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-51.pdf).

Mammograms have a wrinkle. The Task Force's current recommendation is a mammogram every 2 years for women 40 to 74. For coverage purposes, though, federal law has HHS use the Task Force's 2002 breast cancer screening recommendation (USPSTF A and B recommendations, 2026), and HealthCare.gov lists a screening mammogram every 1 to 2 years for women 40 and older (HealthCare.gov, 2026, healthcare.gov/preventive-care-women). In plain terms, a screening mammogram every one or two years from 40 should be covered at $0 in network.

Vaccines

ACA plans cover adult vaccines recommended by ACIP at no cost sharing in network. HealthCare.gov lists chickenpox, diphtheria, flu, hepatitis A and B, HPV, measles, meningococcal, mumps, whooping cough, pneumococcal, rubella, shingles and tetanus, with doses, ages and populations that vary (HealthCare.gov, 2026, healthcare.gov/preventive-care-adults). The adult schedule posted on the CDC site at the time of this review was labelled 2025, with an addendum updated July 2, 2025 (CDC, 2025, cdc.gov/vaccines/hcp/imz-schedules/adult-age.html). It lists:

• Flu: one dose every year, with high-dose or adjuvanted versions preferred at older ages.
• Tetanus, diphtheria and whooping cough: one dose of Tdap, then a Td or Tdap booster every 10 years.
• Shingles (recombinant zoster vaccine): two doses for adults 50 and older, and for younger adults with certain immune conditions.
• RSV: adults 75 and older, and adults 50 to 74 as described in the schedule notes.
• HPV: through age 26, two or three doses depending on age at the first dose.
• Pneumococcal, hepatitis B, COVID-19 and others: by age and condition as described in the schedule notes. Vaccine recommendations have been revised often, so ask your doctor or pharmacist what applies this season.

Women's preventive services

On top of the general adult list, women have additional covered services, many drawn from the HRSA-supported guidelines. HealthCare.gov lists, among others: well-woman visits, a screening mammogram every 1 to 2 years from 40, cervical cancer screening from 21 to 65, bone density screening for women over 65 and for younger women who have gone through menopause, BRCA risk assessment and genetic testing guidance for women at higher risk, screening for domestic and interpersonal violence, yearly urinary incontinence screening, diabetes screening after a pregnancy with gestational diabetes, birth control and contraceptive education, and a range of pregnancy-related screenings (HealthCare.gov, 2026, healthcare.gov/preventive-care-women). In Colorado, contraception is also covered at its total cost without cost sharing under section 10-16-104(18.1), C.R.S. (SB21-016 signed act, 2021).

Colorado extras worth using

• An annual mental health wellness exam. Colorado's benchmark plan for individual and small-group coverage includes one 45 to 60 minute visit per plan year with a qualified mental health provider, which can include screening, lifestyle consultation, referrals and a discussion of medication options (Colorado DOI, October 12, 2021, doi.colorado.gov/news-releases-consumer-advisories/biden-administration-announces-approval-of-colorados-inclusive).
• Colorado Option plans set $0 preventive care, $0 mental and behavioral health office visits with no visit limit, $0 diabetes supplies including continuous glucose monitors, and $0 primary care visits on gold and silver (Colorado Regulation 4-2-81, Appendix A).
• STI prevention services and screening for all covered persons regardless of gender, under section 10-16-104(18)(b)(XI), C.R.S.

A worked example: one preventive year for an Adams County couple

Hypothetical Colorado household, not a real client. A Brighton couple is enrolled in a Colorado Option Silver plan for 2027. She is 52. He is 58, carries extra weight, and quit smoking eight years ago after about 25 pack-years. Here is what their screening year looks like, using the USPSTF intervals above and the 2027 Colorado Option Silver design: preventive care $0, primary care visits $0 with no limit, Tier 2 drugs $20, and lab tests and x-rays at 40% after a $5,000 deductible (Colorado Regulation 4-2-81, Appendix A).

What the example shows

• A full year of recommended screening for two adults can cost $0 in network, including follow-up steps people often assume will be billed.
• The bill appears when care becomes diagnostic: the knee x-ray, not the visit, is what goes toward the deductible.
• Plan design matters. On a non-Colorado Option plan, that knee pain visit could carry a copay or count toward the deductible; read the primary care row of the SBC.
• Using every preventive benefit has real value even in a healthy year, because the cost of skipping a screening shows up later.

When a $0 visit produces a bill

None of this means you should stay quiet at your visit. It means knowing what to expect, and asking the office how a visit or a test will be coded if cost is a concern.

• You raise a new problem during a preventive visit. The diagnostic part can be billed under your regular cost sharing.
• A test is ordered to investigate a symptom rather than to screen. Diagnostic labs and imaging follow the plan's normal rules.
• The provider or lab is out of network. The no-cost rule applies in network.
• The service is outside the recommendation, such as a test more often than the interval or outside the age range.
• Treatment after a finding. Screening and its integral steps are covered; treating what is found is not preventive.

Plans that do not have to follow these rules

Short-term medical plans, fixed indemnity policies and health care sharing ministries are not required to cover preventive care at no cost. Grandfathered plans, which have existed since before March 2010 and are now rare, may also be exempt. If $0 preventive care matters to you, an ACA plan is the safer choice. At 65, Medicare takes over with its own preventive benefits, including the Welcome to Medicare visit and the yearly Wellness visit.

What Lisa checks for you

Lisa's approach is to ask questions, listen to the answers, and only then recommend the type of plan that fits. For preventive care, that means making sure the plan's network supports the visits and screenings a household is due for.

• That your primary care provider, your preferred imaging center and the lab your doctor uses are all in network for 2027.
• Whether a Colorado Option plan in your county includes your doctors, since its $0 primary care and mental health office visits remove a common source of surprise bills.
• The preventive and primary care rows of each finalist's Summary of Benefits and Coverage.
• Your current prescriptions on each drug list, including any preventive medication.
• For clients nearing 65, how preventive care changes when Medicare starts.

Questions to ask your doctor's office and your plan

• Which screenings am I due for this year, based on my age and history?
• Will this visit or test be billed as preventive or diagnostic?
• Is the lab or imaging center you use in my plan's network?
• If my stool test is positive, will the follow-up colonoscopy be billed as part of the screening?
• Does my plan cover a yearly adult preventive exam, and how is it coded?
• How do I schedule the annual mental health wellness exam?

A simple yearly checklist

• Book your preventive or well-woman visit with an in-network primary care provider.
• Ask which screenings are due for your age and history, and get them scheduled at in-network facilities.
• Get your flu shot in the fall and ask about any other vaccines that are due.
• Use an in-network lab for any blood work.
• Review your Explanation of Benefits afterward, and call the insurer if a preventive service was billed to you.

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The bottom line

Preventive care is one of the most valuable parts of an ACA plan, and it is built on specific federal recommendations, not a general promise of a yearly physical. Know which screenings are due for your age, stay in network, and ask how each test is coded. In Colorado, state law and the Colorado Option plans add even more at $0. If you are choosing a plan and want to be sure your doctors and labs are in network, send Lisa a message or call (303) 887-8584.