Patient Guide

Preventive Care — What's Covered, What Costs Money, and Why It Matters

Most people leave preventive care on the table. Under the Affordable Care Act, your insurance is required to cover a broad range of preventive services — screenings, immunizations, and wellness visits — at absolutely no cost to you. No copay. No deductible. No coinsurance. But there's a catch: you have to know what's covered, come in to get it, and understand the difference between a preventive visit and a sick visit so you don't end up with a surprise bill. This guide explains all of it.

The Basics

Preventive Visit vs. Sick Visit — They're Billed Differently

This is the distinction that causes more patient confusion — and more surprise bills — than almost any other aspect of primary care billing. Understanding it before your appointment can save you money.

Preventive Visit — Typically $0 Cost

You come in to stay well

Annual wellness exam or physical — no symptoms, no specific concern
Routine screenings appropriate for your age and sex
Immunizations and vaccines
Health risk assessment and counseling
Covered at no cost under the ACA for most non-grandfathered plans
Must be with an in-network provider to be covered at $0
Must be the primary reason for the visit — not combined with a sick concern

Sick Visit — Subject to Copay / Deductible

You come in because something is wrong

You have a specific symptom or concern — cold, ear pain, rash, chest tightness
Follow-up for a chronic condition — blood pressure check, diabetes management
Evaluation of a new or existing problem
Prescription refill tied to an ongoing condition
Billed as a diagnostic or office visit — subject to your copay and deductible
Even if you come in for your annual and raise a new concern, that concern may be billed separately as a sick visit

Why your annual physical sometimes results in a bill

This is one of the most common and frustrating billing surprises in primary care. You schedule your annual physical — it's supposed to be free. But you mention your knee has been bothering you, or you bring up a new medication concern, and suddenly you get a bill.

Here's why: insurance distinguishes between preventive care and problem-focused care. The moment your provider addresses a specific clinical concern beyond the preventive screening, that additional service may be billed separately — and that portion is subject to your copay or deductible.

The fix: if you have specific concerns beyond your annual wellness exam, let us know upfront. We may recommend scheduling a separate visit so the preventive portion stays covered at $0 and you know exactly what to expect for the rest.

What the Law Says

What the ACA Requires Your Insurance to Cover

The Affordable Care Act requires most private health insurance plans to cover a broad list of preventive services at no cost to you — as long as you see an in-network provider and the preventive service is the primary reason for your visit.

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Confirmed in 2025: These coverage requirements are still the law

In June 2025, the United States Supreme Court upheld the constitutionality of the ACA's preventive services mandate, confirming that insurers remain required by federal law to cover USPSTF-recommended preventive services without cost sharing. Your no-cost preventive care coverage is intact.

The services covered fall into four categories: recommendations from the U.S. Preventive Services Task Force (USPSTF), immunization recommendations from the Advisory Committee on Immunization Practices (ACIP), children's preventive services under the Bright Futures guidelines, and women's preventive services under HRSA guidelines.

Note: grandfathered health plans — plans that have been in continuous existence since before March 23, 2010 — may not be required to cover all preventive services. Short-term health plans are also exempt. If you're unsure whether your plan qualifies, call your insurance company and ask.

What's Included

Common Preventive Services Covered at No Cost

This is not an exhaustive list — the full set of covered services depends on your age, sex, health history, and specific plan. But these are the services most adults and families should expect to access at no cost.

Annual wellness visit / physical

Adults of all ages — once per year

Blood pressure screening

All adults — routine monitoring

Cholesterol screening

Adults at increased risk — every 5 years

Diabetes (Type 2) screening

Adults 35–70 who are overweight or obese

Colorectal cancer screening

Adults 45–75 — colonoscopy, stool tests, or other approved methods

Mammogram

Women 40+ — annually (varies by plan and guidelines)

Cervical cancer screening (Pap smear)

Women 21–65 — every 3 years or every 5 years with HPV co-test

Depression screening

All adults — annually

Obesity screening and counseling

All adults — BMI assessment and behavioral counseling

Lung cancer screening

Adults 50–80 with a significant smoking history — annual low-dose CT

Flu shot (influenza vaccine)

All adults — annually

COVID-19 vaccine

All adults — per current ACIP recommendations

Shingles vaccine (Shingrix)

Adults 50+ — two-dose series

Tdap / Td booster

Adults — tetanus/pertussis booster every 10 years

Tobacco use counseling

All adults who use tobacco — cessation counseling

Alcohol misuse screening and counseling

All adults — annual screening

Well-child visits

Children — from newborn through age 21 per Bright Futures guidelines

Childhood immunizations

Per ACIP recommended schedule — MMR, varicella, HPV, hepatitis A and B, and others

By Life Stage

Key Screenings by Age Group

Your preventive care needs change as you age. Here's a simplified reference for what to expect at each stage of life.

Screening or service	Who / When	Frequency	Covered at $0?
Annual wellness visit	All adults	Once per year	✓ Yes
Blood pressure check	All adults	At every visit	✓ Yes
Cholesterol screening	Adults at risk	Every 4–6 years	✓ Yes
Diabetes screening	Adults 35–70, overweight/obese	Every 3 years	✓ Yes
Colorectal cancer screening	Adults 45–75	Every 1–10 years depending on method	✓ Yes
Mammogram	Women 40+	Annually	✓ Yes
Pap smear / cervical cancer screening	Women 21–65	Every 3–5 years	✓ Yes
Lung cancer screening (low-dose CT)	Adults 50–80, heavy smoking history	Annually	✓ Yes
Depression screening	All adults	Annually	✓ Yes
Flu shot	All adults	Annually (fall)	✓ Yes
Shingles vaccine (Shingrix)	Adults 50+	Two doses, 2–6 months apart	✓ Yes — for most plans
Bone density scan (DEXA)	Women 65+ or younger women at risk	Every 1–2 years	✓ Yes

Frequency and eligibility vary by individual health history and plan. Your provider will help determine which screenings are appropriate for you at your annual wellness visit.

Why This Matters

Preventive Care Isn't Just Paperwork — It Saves Lives

The reason insurance is required to cover these services isn't bureaucratic. It's because catching things early — before symptoms appear — consistently leads to better outcomes, less invasive treatment, and lower long-term costs.

The best time to find a problem is before you have symptoms.

Colon cancer caught at stage 1 has a 90%+ survival rate. Caught at stage 4, that drops dramatically. High blood pressure identified and treated early prevents heart attacks and strokes. Diabetes caught in the prediabetes stage is often reversible with lifestyle changes alone. Depression screened and identified early responds better to treatment. Preventive care isn't a formality — it's the most efficient investment you can make in your own health.

At Burds Family Practice, your annual wellness visit is how we stay ahead of things for you. We track your numbers over time, flag changes, order the screenings you're due for, and make sure you're not leaving free, potentially life-saving care on the table.

If you haven't had a wellness exam in the past year — or you've been skipping them because you assumed there would be a charge — call us. For most patients with non-grandfathered insurance, the visit is covered at no cost.

Common Questions

Frequently Asked Questions

What is preventive care?

Preventive care refers to health services designed to prevent illness, detect conditions early, or manage risk factors before they become serious problems. It includes annual wellness visits, screenings, immunizations, and counseling. Unlike a sick visit — where you come in because something is wrong — preventive care is proactive. You come in to stay well and catch things before they develop into bigger problems.

Is preventive care covered by insurance?

Under the Affordable Care Act, most private health insurance plans are required to cover a broad range of preventive services at no cost to the patient — no copay, no deductible, no coinsurance. This applies when the service is performed by an in-network provider and is the primary reason for the visit. In June 2025, the Supreme Court upheld the constitutionality of these requirements, confirming that insurers must continue to cover USPSTF-recommended preventive services.

What is the difference between a preventive visit and a sick visit?

A preventive visit — also called a wellness exam or annual physical — is scheduled when you are not sick and focuses on screenings, immunizations, and health risk assessment. It is typically covered at no cost by insurance. A sick visit is scheduled because you have a specific symptom or concern, and is billed differently — usually subject to a copay or deductible. If you come in for your annual physical and also bring up a new health concern at the same visit, your insurance may bill that second issue separately as a sick visit charge.

Why does my annual physical sometimes result in a bill?

If you come in for a preventive visit and your provider addresses a new or separate clinical concern during the same appointment, that additional service may be billed separately and subject to your copay or deductible. Insurance distinguishes between preventive care and problem-focused care. To avoid surprise bills, let your provider know upfront if you want to keep the visit purely preventive, or schedule a separate appointment for any additional concerns.

What preventive services are covered at no cost?

Preventive services covered at no cost under the ACA include annual wellness visits, blood pressure screening, cholesterol screening, diabetes screening, colorectal cancer screening, mammograms, cervical cancer screening, depression screening, obesity counseling, lung cancer screening for high-risk adults, immunizations including flu shots and COVID-19 vaccines, and many more. The specific services covered depend on your age, sex, health history, and insurance plan.

When did you last have
a wellness visit?

If it's been more than a year — or you've never scheduled one — call us. For most patients, it's covered at no cost. It takes an hour and it matters.

Schedule a Wellness Visit Call Us: (563) 588-6659