What the Requirement Is
Under the ACA, non-grandfathered group health plans and insurance carriers must cover certain preventive services at 100%, with no deductible, copay or coinsurance, when they’re provided in-network. The goal is to remove cost as a barrier to screenings, immunizations and other preventive care.
Grandfathered plans aren’t required to follow this rule.
In 2025, the U.S. Supreme Court upheld the requirement in Kennedy v. Braidwood, so it remains in effect.
Which Services Are Covered
The required services come from recommendations by:
- U.S. Preventive Services Task Force (USPSTF): Services rated “A” or “B”
- Advisory Committee on Immunization Practices (ACIP): Routine immunizations for children and adults
- Health Resources and Services Administration (HRSA): Guidelines for infants, children and adolescents, and women’s preventive services, such as well-woman visits and contraception
When a recommendation is added or changed, plans generally must reflect it for plan years beginning one year after it’s issued. For a current list of covered services, see HealthCare.gov’s preventive care page.
Things to Know
- In-network only: Preventive services from out-of-network providers may be subject to the plan’s normal cost sharing.
- Keeping up with changes: For fully insured plans, the carrier updates coverage as recommendations change. For self-funded and level-funded plans, the plan’s administrator or TPA typically tracks updates.
Important: This information is provided for general educational purposes. It is not legal or tax advice. How these rules apply depends on each employer’s specific circumstances, so employers should review their situation with their own legal counsel, ERISA attorney, CPA or tax advisor.