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What is the ACA's preventive health services coverage mandate?
The Affordable Care Act (ACA) requires nearly all health plans to cover a wide range of free preventive care benefits (meaning the patient doesn’t have to pay any deductibles, copayments, or coinsurance).
What preventive health services are free under the ACA’s mandate?
Services have to fall into one of three categories in order to be under the umbrella of preventive care that non-grandfathered health insurance plans must provide at no cost to the consumer. (The cost of preventive care is wrapped into the premiums that we all pay each month.)
- Wide-ranging preventive care for everyone – services rated "A" or "B” in the current United States Preventive Services Task Force (USPSTF) recommendations. As detailed below, the Supreme Court has upheld the authority of the USPSTF to make preventive care recommendations, and health plans must continue to fully cover services that have an "A" or "B" rating from USPSTF.1
- Preventive care for women and children – recommended in the guidelines from the Health Resources and Services Administration (HRSA), including the Bright Futures recommendations for children (infancy through age 21) and the Women's Preventive Services Guidelines. This care includes no-cost female contraception coverage, which has been challenged in court and subject to evolving rules under different presidential administrations (details below).The Centers for Medicare & Medicaid Services (CMS) also published FAQs in 2022 and 2024, addressing a variety of specific details in terms of what health plans are required to provide in terms of contraceptive coverage. Additional proposed rules were published in 2024, calling for non-grandfathered health plans to be required to cover the cost of over-the-counter contraception, including Opill, without any cost-sharing for the enrollee2 but this proposal was withdrawn by the Biden administration in January 2025.3
- Vaccines for children and adults – recommended by the Centers for Disease Control & Prevention's Advisory Committee on Immunization Practices (ACIP). Numerous immunizations are recommended, including those for influenza, meningitis, tetanus, pertussis, mumps, measles, rubella, varicella, HPV, hepatitis A and B, and COVID-19. Some vaccine recommendations are age-specific, such as the recommendation that people get vaccinated against shingles once they're at least 50 years old.4
(Note that only routinely recommended vaccines are required to be covered by health insurance. So for example, health plans do not have to cover the cholera vaccine, as that's only recommended for people who will be traveling to an area where cholera transmission is active.5)
In 2025, the Secretary of HHS removed all of the members of ACIP and replaced them with several new members who have a history of being skeptical of vaccines.6 But AHIP, which represents health plans, issued a statement signaling health plans' commitment to continuing to cover vaccines.7
KFF's preventive services tracker includes a note for each service, clarifying which body recommends it.
What happened with the legal challenge to the ACA's preventive coverage mandate?
In June 2025, the Supreme Court ruled that the ACA's preventive services mandate is constitutional.1 The crux of the case hinged on whether the USPSTF members were properly appointed, and thus whether their recommendations could be used as guidance for the preventive services that health plans must follow. The Court ruled that the appointment of USPSTF members by the Secretary of HHS is constitutional, thus upholding their authority to set preventive service coverage guidelines.8
We don't yet know whether the HHS Secretary will appoint new members to the USPSTF (as he did with ACIP in June 2025), but non-grandfathered health plans will continue to have to fully cover the cost of preventive care recommendations made by USPSTF (and also those made by HRSA and ACIP).
Here's a summary of how the Braidwood case unfolded:
- In March 2023, a federal trial court overturned some aspects of ACA’s preventive services coverage requirement, in Braidwood v. Becerra (later known as Kennedy v. Braidwood).9 Specifically, the ruling said that health plans no longer had to cover USPSTF recommendations made since March 23, 2010, when the ACA was enacted. The ruling did not allow health plans to stop covering preventive services that were already recommended by USPSTF prior to March 23, 2010.10 But most USPSTF recommendations have been updated since 2010. So if the ruling had been upheld, health plans could have reverted to the recommendations that existed in 2010.
- The 2023 ruling stated that requiring health plans to cover services recommended by the USPSTF violated the Appointments Clause of the U.S. Constitution, because members of the USPSTF have not been nominated by the president or confirmed by the Senate. (This is by design. Congress intended this body to be comprised of experts who are free from political interference. On each USPSTF recommendation page, they clarify that “Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.”11
- The Department of Justice appealed the ruling10 to the 5th Circuit Court of Appeals in New Orleans, and asked the court for a temporary stay.12 That was granted in May 2023, in a move that was applauded by numerous patient advocacy groups.
- The following month, an agreement was reached that put the trial court’s ruling on hold throughout the appeals process, meaning that preventive services would continue to be covered while the case was appealed.13
- In June 2024, the appeals court issued a “mixed bag” ruling.14 The ruling allowed the plaintiffs in the case to no longer provide coverage that included zero-cost preventive care recommended by the USPSTF.(The plaintiffs included some individuals but also two Texas-based businesses: Braidwood Management, which self-insures health coverage for about 70 employees, and Kelley Orthodontics, both of whom objected on religious grounds to certain aspects of the preventive coverage mandate.)9 But it overturned the district court’s ruling that had extended that provision to all health plans. The appeals court also sent the case back to the lower court for further review of the coverage requirements under HRSA and ACIP recommendations,15 but in late August 2024, the case was stayed pending a ruling from the Supreme Court.
- In early 2025, the Supreme Court agreed to hear the case during the 2025 term, but with a narrow focus on just the USPSTF-related issues. Future litigation could eventually make its way to the Supreme Court related to other aspects of preventive coverage rules.16 Oral arguments were heard on April 21,17 and the Court upheld the ACA's preventive care mandate in June 2025.1 Specifically, the Supreme Court ruled that the USPSTF members are "inferior officers" (rather than principal officers), and thus their appointment by the Secretary of HHS (as opposed to by the President with confirmation by the Senate) is constitutional.1
- Because of the Supreme Court ruling, nothing will change about the ACA's preventive care mandate. Services recommended by USPSTF (as well as HRSA and ACIP) will continue to be covered (with no out-of-pocket costs) by grandfathered health plans. But as noted above, USPSTF membership could change over time, resulting in changes to the recommendations.
- A note about HIV prevention medications: The lower court’s ruling specifically overturned the requirement that PrEP HIV prevention drugs be covered by the plaintiffs' health plans, to avoid violating plaintiffs' religious freedoms.9 But PrEP is covered by health plans because it has an "A" rating from USPSTF, issued in 2019.18 The Supreme Court did not consider the plaintiffs' claims that having to cover PrEP violates their religious freedoms.16 And since PrEP is covered due to a USPSTF recommendation, the Court's decision to uphold USPSTF authority means that PrEP must continue to be covered as preventive care.
- The lower court’s ruling did not affect HRSA (Health Resources and Services Administration) recommendations regarding preventive care for children and women, including contraception, nor ACIP (Advisory Committee on Immunization Practices) recommendations regarding vaccines for children and adults. In that case, the lower court rejected the plaintiffs’ arguments against having to cover preventive care recommended by ACIP and HRSA. However, the appeals court remanded this issue back to the district court to determine whether the Health and Human Services (HHS) Secretary has properly ratified ACIP’s and HRSA’s preventive care recommendations.14, 15 The Supreme Court did not consider claims about ACIP or HRSA in 2025. But since those issues are still under consideration by the district court, they could eventually be heard by the Supreme Court in a separate case at a later date.16
Frequently asked questions about ACA’s preventive health services coverage mandate
What are the rules for zero-cost contraception coverage?
Non-grandfathered health plans must cover at least one version of each FDA-approved method of contraception for women without any cost-sharing (meaning free for the enrollee), as long as the contraception is prescribed by a health care provider.
Although non-grandfathered health plans are required to cover all types of FDA-approved female-specific contraception, they’re only required to offer one version of each type with no cost-sharing. They can impose cost-sharing for other versions.
So it’s not true that all contraception is covered for free. Rather, at least one version of each type of female contraception is covered for free. But CMS issued guidance in 2024 to clarify that health plans must have exception protocols to allow women to access, without cost-sharing, specific contraception that’s considered medically necessary for the individual. The guidance noted that the exceptions process cannot “impose unduly burdensome administrative requirements.”19
Starting in 2023, male condoms have to be covered with zero-cost sharing as long as they’re prescribed by a health provider to someone who can become pregnant (so a woman can have coverage for male condoms without cost-sharing as long as her health care provider prescribes them for her).20
The Biden administration issued additional proposed rules in October 2024, that would have required non-grandfathered health plans to cover the cost of over-the-counter contraception, including Opill, spermicides, condoms (for plan enrollees who can become pregnant), and emergency contraception, without any cost-sharing for the enrollee, and without the need for a prescription. This would have been a significant change, as coverage of over-the-counter contraception currently requires a prescription.21
However, the Biden administration opted to withdraw the proposed rule in January 2025, shortly before leaving office.22
Contraceptive coverage was not affected under the Braidwood rulings, although as noted above, the issue of HRSA recommendations was remanded to the district court for further consideration.
There have been other challenges to the contraceptive mandate over the years, and the Trump administration made it easier for health plan sponsors to get an exemption from the coverage requirement if they have religious or moral objections to contraception. The Biden-Harris administration proposed new rules in 2023 that would have rolled back some of those changes and ensured that women could still have access to zero-cost contraception even if their employer or school has a religious exemption. But that proposed rule was never finalized, and was withdrawn in late 2024.23
Do health plans still have to cover vaccines at no cost?
Yes. Non-grandfathered health plans have to fully cover the cost of vaccines recommended by ACIP. But as noted above, the issue of coverage requirements based on ACIP recommendations was remanded to the trial court for further consideration in 2024.
In 2025, the Supreme Court only considered whether the USPSTF has the authority to set coverage requirements (the Court upheld USPSTF authority). But the district court is still considering separate claims regarding HRSA and ACIP recommendations. So that issue could eventually be heard by the Supreme Court in the future.24
In 2025, the Secretary of HHS removed all of the members of ACIP and replaced them with new members, some of whom have a history of being vaccine skeptics.25
But AHIP, which represents health plans, has indicated that U.S. health plans are committed to continuing to cover vaccines.26
Is weight loss treatment covered as a preventive care benefit?
The federally mandated preventive care rules require health plans to cover obesity screening and counseling and diet counseling for people at high risk of chronic disease.27 But federal rules do not require any coverage of other weight loss treatments.
For health plans offered in the individual/family and small group markets, states set their own Essential Health Benefits benchmark plans to define what essential health benefits must be covered by plans issued in the state. Almost half of the states have bariatric surgery in their benchmark plans, but anti-obesity medications are very rarely included. In part, this is because most states’ current benchmark plans date back to 2013, before these medications became available.
Fully insured large group plans are not subject to the ACA’s essential health benefit rules, although states can impose coverage mandates for these plans. Self-insured plans, which cover the majority of people with employer-sponsored coverage,28 are not subject to state rules. They are, however, subject to various federal rules, including ERISA, HIPAA, COBRA, some ACA provisions.
So in most states, the current rules mostly leave it up to insurers and employers in terms of whether they want to cover weight loss drugs. As time goes by, we might see changes to coverage requirements pertaining to weight loss treatment. This could come via updates to federal preventive care guidelines, or changes at the state level via updated benchmark plans and state mandates.
Can states require health plans to cover preventive care at no cost?
For health plans that are regulated at the state level (meaning plans that aren’t self-insured), states can require health plans to continue to cover preventive care with no cost-sharing, even if that requirement were to be eliminated at the federal level.
States can also go beyond federal requirements — for example, by requiring state-regulated plans to cover male contraception, which isn’t required under federal rules.
States can include various preventive care as part of their EHB benchmark plan, which would apply to individual and small group plans, or they can enact legislation that applies to all state-regulated plans, including fully-insured large group plans.
But states do not regulate self-insured health plans, which cover the majority of people who have employer-sponsored health coverage in the U.S.28
Why do some mammograms and colonoscopies have out-of-pocket costs?
Mammograms and colonoscopies are examples of procedures that can be classified as “screening” or “diagnostic” procedures, depending on the circumstances. This matters a lot in terms of health coverage, because health plans are only required to cover the full cost if it’s a screening procedure. If it’s diagnostic, your plan’s regular cost-sharing can apply.
For a mammogram or colonoscopy to be considered a screening procedure, it has to be done on the timelines recommended by USPSTF or HRSA, and in the absence of any symptoms.
- Timing: For mammograms, that means no more than once per year starting at age 40. For colonoscopies, it means no more than once every ten years, starting at age 45. So if you have a screening colonoscopy and a polyp is found and your doctor tells you to come back in three or five years, that second colonoscopy is going to be considered diagnostic (which means there will be out-of-pocket costs), since it will have been less than ten years since your last one.
- Absence of symptoms: The procedure has to be performed simply because it’s time to do so, and not due to anything you or your doctor have noticed. So if you’ve had blood in your stool or have found a lump in your breast, a colonoscopy or mammogram to check things out will be considered diagnostic and there will be out-of-pocket costs. This is true even if you would otherwise qualify for a screening test due to your age. For example, if you’re due for your annual mammogram and your doctor finds a lump during your annual exam and then sends you to get your mammogram, it will be considered diagnostic due to the presence of the lump.
One note about colonoscopies: CMS has confirmed that health plans are not allowed to impose out-of-pocket costs for polyp removal performed during a regular screening colonoscopy (see Q5 in these FAQs), and the plan must also pay for pathology testing for the polyps. So if you go in for a screening colonoscopy and polyps are found, removed, and tested, the health plan still has to cover the procedure with no out-of-pocket costs.
But your doctor will likely then have you return for another colonoscopy in three or five years, and you should expect to have out-of-pocket costs for that follow-up procedure, since it’s being done more frequently than the regular screening schedule.
CMS has also confirmed that if a person opts for a preventive colon cancer screening test other than a colonoscopy (meaning a non-invasive stool-based screening test or direct visualization via flexible sigmoidoscopy or CT colonography) and the results are abnormal, non-grandfathered health plans must cover a follow-up colonoscopy without the patient having to pay any cost-sharing. This is because the USPSTF has noted that in these situations, “follow-up with colonoscopy is needed for further evaluation.”29
Medicare and Colonoscopies: The coverage rule is different for Original Medicare, which does impose cost-sharing if a polyp is found and removed during a screening colonoscopy.30
But Medicare’s out-of-pocket costs related to polyps found during screening colonoscopies are gradually being phased out due to legislation that was enacted in 2021.
Other services covered by Medicare Part B have 20% coinsurance, but the coinsurance for polyps on screening colonoscopies has been reduced to 15%. It will be 10% from 2029 to 2029, and then waived entirely starting in 2030.31
Does health insurance cover preventive care as soon as experts recommend it?
In normal circumstances, there’s a delay that can last nearly two years before recommendations from USPSTF, HRSA, or ACIP are built into health insurance plans. But for COVID-19 vaccines, that was shortened to just 15 business days. ACIP finalized their recommendation for the COVID-19 vaccine in mid-December 2020, so all non-grandfathered health plans had to cover COVID-19 vaccines with zero-cost sharing as of early January 2021 (which was well before the vaccines were available for most people).
Preventive care recommendations have evolved considerably over time, and the recommendations have been gradually incorporated into health coverage as they were updated. For example, in 2021, USPSTF lowered the recommended age to begin screening colonoscopies from 50 to 45, and health plans had until 2023 to implement that change (many of them did so well before that).
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
Footnotes
- "Kennedy v. Braidwood" Supreme Court of the United States. June 27, 2025 ⤶ ⤶ ⤶ ⤶
- "Enhancing Coverage of Preventive Services Under the Affordable Care Act" U.S. Departments of the Treasury, Labor, and Health & Human Services. Oct. 23, 2024 ⤶
- "Enhancing Coverage of Preventive Services Under the Affordable Care Act" Withdrawal of a proposed rule by the Internal Revenue Service, the Employee Benefits Security Administration, and the Health and Human Services Department. Jan. 15, 2025 ⤶
- “Vaccine Schedule for You and Your Family” CDC; Advisory Committee on Immunization Practices (ACIP). Accessed June 23, 2024 ⤶
- "Cholera Vaccine: Recommendations of the Advisory Committee on Immunization Practices, 2022" CDC. Sep. 30, 2022 ⤶
- "Inside the unusual, RFK-appointed panel that's deciding on childhood vaccines" USA Today. June 26, 2025 ⤶
- "Health Plans' Continued Commitment to Vaccine Access" AHIP. June 24, 2025 ⤶
- "X thread explaining the Braidwood decision" Nicholas Bagley, Administrative and Health Law Professor, University of Michigan Law School. June 27, 2025 ⤶
- “Explaining Litigation Challenging the ACA’s Preventive Services Requirements: Braidwood Management Inc. v. Becerra” KFF.org. May 15, 2023 ⤶ ⤶ ⤶
- “Braidwood Management, Inc. et al, Plaintiffs, v. Xavier Becerra, et al., Defendants” United States District Court. March 31, 2023 ⤶ ⤶
- “US Preventive Services Task Force” Accessed June 23, 2024 ⤶
- “PAN joins health groups applauding stay in Braidwood v. Becerra lawsuit to protect coverage for preventative services” panfoundation.org. April 13, 2023 ⤶
- “Joint Stipulation and Proposed Order; Braidwood v. Becerra” U.S. Court of Appeals, 5th Circuit. June 12, 2023 ⤶
- “Braidwood v. Becerra” United States Court of Appeals for the Fifth Circuit. June 21, 2024 ⤶ ⤶
- “Overview of Braidwood v. Becerra ruling” Nicholas Bagley, Law Professor at Michigan Law School. June 21, 2024 ⤶ ⤶
- "ACA Preventive Services Are Back at the Supreme Court: Kennedy v. Braidwood" KFF.org. Apr. 15, 2025 ⤶ ⤶ ⤶
- "April session to feature religious charter school case and challenge to LGBTQ+ books in schools" SCOTUS Blog. Feb. 24, 2025 ⤶
- "Prevention of Acquisition of HIV: Preexposure Prophylaxis" USPSTF. Aug. 23, 2023 ⤶
- “FAQs About Affordable Care Act Implementation Part 64” CMS.gov. Jan. 22, 2024 ⤶
- ”2023 & Free: You May Never Have to Pay for Condoms Again!” National Women’s Law Center. February 1, 2023. ⤶
- ”Enhancing Coverage of Preventive Services Under the Affordable Care Act” U.S. Departments of the Treasury, Labor, and Health & Human Services. Oct. 23, 2024 ⤶
- ”Enhancing Coverage of Preventive Services Under the Affordable Care Act” Withdrawal of a proposed rule by the Internal Revenue Service, the Employee Benefits Security Administration, and the Health and Human Services Department. Jan. 15, 2025 ⤶
- ”Coverage of Certain Preventive Services Under the Affordable Care Act” U.S. Departments of the Treasury, Labor, and Health & Human Services. Dec. 30, 2024 ⤶
- ”ACA Preventive Services Are Back at the Supreme Court: Kennedy v. Braidwood” KFF.org. Apr. 15, 2025 ⤶
- ”Inside the unusual, RFK-appointed panel that’s deciding on childhood vaccines” USA Today. June 26, 2025 ⤶
- ”Health Plans’ Continued Commitment to Vaccine Access” AHIP. June 24, 2025 ⤶
- “Preventive care benefits for adults” HealthCare.gov. Accessed June 23, 2024 ⤶
- “Employer Health Benefits, 2024 Annual Survey” KFF. Oct. 9, 2024. ⤶ ⤶
- ”Colorectal Cancer: Screening” USPSTF. May 18, 2021 ⤶
- “Colonoscopies” Medicare.gov. Accessed June 23, 2024 ⤶
- ”Medicare claims processing manual, chapter 18 – preventive and screening services” Centers for Medicare & Medicaid Services. Revised Oct. 11, 2024. ⤶