Under ACA Section 2713, non-grandfathered Marketplace plans must cover three categories of preventive services without cost-sharing when those services are delivered by an in-network provider. The law does not create a blanket zero-cost guarantee for every service a client thinks of as preventive. Two words carry the most weight: in-network.
Key Takeaways
- ACA Section 2713 requires plans to cover preventive services in three buckets without cost-sharing: USPSTF Grade A or B recommendations, ACIP vaccine recommendations, and HRSA women's and children's preventive guidelines. All three buckets must be offered by non-grandfathered Marketplace plans.
- The $0 cost-sharing guarantee is in-network only. If a client sees an out-of-network provider for a preventive visit, the plan can apply the full deductible. Brokers need to flag this before enrollment.
- New USPSTF recommendations are not required to be covered until the plan year starting at least one year after the recommendation is issued. A recommendation published in October 2026 does not have to be covered until 2028 plan years.
- Federal litigation has challenged whether USPSTF recommendations issued after March 2010 are enforceable under the Appointments Clause. Carriers have responded differently, and coverage for specific services may vary by plan and year.
- A preventive visit billed under the wrong CPT code can convert a $0 service into a cost-sharing event. The billing code determines how the claim is adjudicated, not the client's intention to come in for a wellness check.
The three preventive service buckets
Section 2713 ties the coverage requirement to three separate bodies, each with its own scope and rulemaking process. A service is not covered at $0 simply because it is medically preventive. It must appear in one of the three lists below with the required rating or recommendation status.
| Bucket | Authority | Examples | Key note |
|---|---|---|---|
| USPSTF Grade A or B | U.S. Preventive Services Task Force | Colorectal cancer screening, mammography, blood pressure screening, cholesterol screening, diabetes screening, lung cancer screening, cervical cancer screening, HIV testing, tobacco cessation counseling, depression screening | Post-2010 recommendations under litigation. Confirm with carrier for specific plan year. |
| ACIP vaccine recommendations | Advisory Committee on Immunization Practices (CDC) | Flu shot, COVID-19 vaccines, hepatitis A and B, HPV, pneumococcal, shingles (Shingrix), MMR, varicella, Tdap, RSV for adults over 60 | Applies to vaccines recommended for any age group or population. In-network pharmacy and provider both qualify. |
| HRSA women's and children's guidelines | Health Resources and Services Administration | Well-woman visits, breastfeeding support and supplies, contraceptive counseling and methods, gestational diabetes screening, HPV DNA testing, interpersonal violence screening | Religious exemptions for contraceptive coverage apply to some employer-sponsored plans. Not applicable to most individual Marketplace plans. |
Illustrative examples. Coverage for specific services depends on plan year, carrier, and current regulatory status. Confirm with the carrier before advising clients.
The in-network rule most clients discover too late
The $0 cost-sharing requirement applies only when the service is delivered by an in-network provider. A client who drives to an out-of-network specialist for a preventive mammogram does not receive the Section 2713 protection. The carrier can apply the full out-of-network cost-sharing, including the deductible, to that claim.
For HMO and EPO plans, the in-network requirement is especially sharp because those plan types have no out-of-network coverage at all for non-emergency services. A client on an HMO plan whose primary care doctor refers them to an out-of-network specialist for a colonoscopy will receive a bill that has nothing to do with preventive care protections. Brokers advising clients with significant preventive care needs should run a network check on the specific provider before the plan is selected, not after the claim arrives. GetInsured and similar enrollment platforms surface plan data but rarely confirm how specific providers bill preventive CPT codes under a given plan. That check requires a direct carrier call or provider billing inquiry.
The billing code problem
Preventive care protections apply when the claim is adjudicated under a preventive service billing code. The most common failure mode: a client books a wellness visit, mentions a symptom, and the physician adds a diagnostic evaluation to the appointment. The claim comes back split: the preventive portion billed at $0 and the diagnostic evaluation billed at the plan's office visit cost-sharing rate.
This is legal. CMS allows carriers to split-bill when a single visit includes both preventive and diagnostic services. The practical result is that a client who expected a $0 annual visit receives a bill for $40 to $80 because of a symptom mentioned in passing. The advice that prevents this: schedule preventive and diagnostic visits separately. A client who has a concern about a skin lesion should book a preventive annual visit and a separate follow-up for the lesion, not mention it during the wellness appointment.
The plan year transition rule
When USPSTF issues a new Grade A or B recommendation, plans are not immediately required to add it. Coverage is required starting with plan years that begin at least one year after the recommendation takes effect. A recommendation published in November 2026 would not be required until plan years beginning on or after November 2027.
For calendar-year plans (which most Marketplace plans are), this means a new recommendation issued anytime during 2026 would not be required until January 2028 at the earliest. Carriers may voluntarily add coverage sooner. If a client is specifically seeking a recently recommended preventive service, confirm with the carrier before enrollment rather than assuming the service is automatically covered at $0. For a clear look at how plan costs stack around preventive coverage decisions, the ACA metal tiers explained post covers how plan actuarial values interact with the services clients actually use.
The Braidwood litigation and what brokers should tell clients
Federal courts have examined whether USPSTF recommendations issued after March 23, 2010, when the ACA was signed, are enforceable under the Appointments Clause of the U.S. Constitution. The argument in Braidwood Management v. Becerra was that USPSTF members were not constitutionally appointed and therefore lacked authority to issue binding coverage mandates.
As the case worked through the courts, carriers responded unevenly. Some continued covering the full list of USPSTF recommendations at $0 pending final resolution. Others flagged specific post-2010 services as under review. HIV prevention (PrEP), which received a Grade A recommendation in 2019, was among the services most directly at issue.
For broker purposes: ACIP vaccines and HRSA women's and children's guidelines are on different statutory footing and have not been subject to the same Appointments Clause challenge. Annual flu shots, childhood immunizations, and women's preventive care are unlikely to be affected by the Braidwood outcome. For USPSTF-specific items, verify with each carrier for the current plan year.
Vaccines: a cleaner case than USPSTF
ACIP vaccine recommendations face a simpler coverage picture. The Advisory Committee on Immunization Practices operates under the CDC, and its recommendations for vaccines have not been subject to the Appointments Clause challenge that affected USPSTF. Every ACIP-recommended vaccine for any age group or population must be covered at $0 by non-grandfathered plans.
The in-network requirement still applies. A flu shot administered at an in-network pharmacy or provider is $0. One administered at an out-of-network urgent care clinic may not be. For clients whose children receive vaccines through a specific pediatric practice, confirm that the practice is in-network before each plan year, as network contracts can change at renewal. For the detailed pediatric coverage picture under ACA, including which benefits are required for members under 19, see the ACA dental and vision coverage broker guide.
Broker checklist before recommending a plan with preventive care priority
For clients who identify preventive care access as a high priority at enrollment, the due diligence goes beyond confirming the plan type.
Confirm that the client's primary care provider is in-network on the specific plan being recommended. Directory errors are documented in CMS audits. A direct call to the provider's billing office asking whether they accept the carrier and plan takes three minutes and prevents a larger problem.
Confirm how the provider bills preventive visits. Providers who primarily serve commercially insured patients typically bill under standard preventive codes. Providers who see a high volume of Medicaid or capitated patients sometimes have billing workflows that default to diagnostic codes even for wellness visits.
If the client is on a specific medication that received a new USPSTF recommendation (PrEP is the clearest example as of 2026), call the carrier before enrollment to confirm current coverage status and applicable tier.
FAQ
Questions brokers and clients ask about ACA preventive care coverage.
Does preventive care coverage apply to all ACA Marketplace plans?
It applies to all non-grandfathered plans, which includes virtually every plan sold on or off the Marketplace since 2010. Grandfathered plans are those that existed before March 23, 2010 and have not made significant changes. In practice, grandfathered plans represent a very small share of the current market. If a client is enrolling in a Marketplace plan today, they are almost certainly enrolling in a non-grandfathered plan subject to Section 2713.
My client went to their primary care doctor for a wellness visit and got billed a copay. How did the $0 guarantee fail?
Billing code mismatch is the most common cause. A visit billed under a primary care office visit code (99213, for example) can trigger a copay even if the appointment was for preventive purposes. The preventive visit codes (99381 through 99397 for evaluation and management, or G0402 for Welcome to Medicare visits) are what trigger the $0 cost-sharing. If a physician also diagnoses and treats a condition during the same visit, carriers commonly split-bill: the preventive portion at $0 and the diagnostic portion at normal cost-sharing. Remind clients to schedule preventive visits as separate appointments from diagnostic concerns.
What is the Braidwood v. Becerra case and what does it mean for clients right now?
Braidwood Management v. Becerra is federal litigation that challenged whether USPSTF recommendations issued after the ACA was signed in March 2010 are enforceable, arguing that USPSTF members were not constitutionally appointed. The case moved through the federal courts and created uncertainty about whether post-2010 recommendations, including PrEP coverage for HIV prevention, are legally required. As of mid-2026, carriers have taken varying positions on specific services pending final resolution. Brokers should verify with each carrier which services are currently covered at $0 in their specific plans rather than assuming the entire USPSTF list applies uniformly.
Can a carrier require prior authorization for a preventive service before covering it at $0?
CMS guidance clarifies that plans cannot impose prior authorization requirements on preventive services in a way that effectively negates the $0 cost-sharing requirement. A plan that requires prior authorization for colorectal cancer screening, for example, and then denies or delays the authorization, would be creating a barrier that violates Section 2713. In practice, some carriers require referrals for certain services in HMO plans. The distinction is between an in-network referral process (permitted) and a prior authorization that can be denied (not permitted for covered preventive services).
If a new USPSTF Grade A recommendation is issued in November 2026, when must plans start covering it?
Plans must cover the new recommendation starting with plan years beginning at least one year after the effective date of the recommendation. For a November 2026 recommendation, a calendar-year plan would not be required to add coverage until the plan year starting January 1, 2028. There is no requirement for mid-year addition of new recommendations. However, carriers may voluntarily add coverage sooner. Brokers advising clients with specific preventive care needs should not assume coverage for recently issued recommendations until the plan year transition has occurred.
