- More than 100 preventive services are covered at $0 cost-share under ACA Section 2713 — no copay, deductible, or coinsurance
- Coverage includes annual physicals, mammograms, colonoscopies, all ACIP vaccines, contraception, well-child visits, mental health screening, and more
- Connecticut state law (CGS § 38a-503 series) requires additional coverage for CT-regulated plans: mammograms at 35, follow-up diagnostic mammograms at $0
- Use in-network providers and labs — out-of-network preventive services may be billed at full cost-share
- Polyp removal during screening colonoscopy must be billed at $0 (IRS Notice 2023-37) — dispute any charges
- Schedule new health complaints separately from annual physical to avoid problem-focused billing
- Get vaccines at in-network pharmacies (CVS, Walgreens, etc.) to avoid office visit billing entirely
- Dispute surprise preventive bills with insurer, CT Insurance Department, or Office of the Healthcare Advocate (1-866-466-4446)
Section 2713 of the Affordable Care Act requires all non-grandfathered health plans — including Connecticut Marketplace plans, employer plans, Medicaid (HUSKY), and Medicare — to cover more than 100 preventive services at $0 cost-share when delivered by an in-network provider. No deductible. No copay. No coinsurance. Despite this, roughly 15% of Connecticut patients receive surprise bills for supposedly ‘free’ preventive care each year because of subtle billing coding issues. This 2026 guide explains every covered service, every billing trap, and exactly what to say at the front desk to keep your visit at $0.
What’s Covered at $0 Cost-Share in 2026
ACA Section 2713 requires coverage at $0 cost-share for four categories of preventive services: (1) USPSTF Grade A or B recommendations, (2) CDC Advisory Committee on Immunization Practices (ACIP) recommended vaccines, (3) HRSA Bright Futures pediatric guidelines, and (4) HRSA Women’s Preventive Services Guidelines. The lists are updated annually; 2026 includes several new and expanded services.
Categories of $0 Preventive Care in 2026
- USPSTF Grade A & B screenings (cancer, cardiovascular, behavioral, metabolic)
- ACIP-recommended vaccines for all ages
- Bright Futures pediatric well-child visits and screenings (age 0-21)
- HRSA Women’s Preventive Services (contraception, breast/cervical cancer, well-woman)
- Tobacco cessation counseling and FDA-approved cessation medications
- Behavioral counseling for obesity, depression, alcohol misuse, intimate partner violence
- STI screening and counseling including HIV PrEP
- Dietary counseling for adults at risk for chronic disease
Connecticut General Statutes mandate additional preventive coverage beyond federal ACA requirements for CT-regulated plans: infertility diagnosis, autism spectrum disorder screening through age 21, mammograms starting at age 35 (not 40), hearing aids for children, and certain prostate cancer screenings. Self-funded ERISA plans are NOT required to follow CT state mandates — only federal ACA rules apply.
Adult Preventive Services Covered at $0
Adult Screenings & Counseling at $0 (USPSTF Grade A/B, 2026)
- Annual wellness visit / annual physical
- Blood pressure screening (all adults)
- Cholesterol screening (men 35+, women 45+, earlier if at risk)
- Type 2 diabetes screening (adults 35-70 with overweight/obesity)
- Hepatitis C screening (all adults 18-79, once-in-lifetime minimum)
- Hepatitis B screening (adults at increased risk, pregnant women)
- HIV screening (all adults 15-65, all pregnant women)
- Lung cancer screening LDCT (adults 50-80 with 20+ pack-year smoking history)
- Tuberculosis screening (adults at increased risk)
- Latent syphilis screening (adults at increased risk)
- Depression screening (all adults)
- Anxiety screening (adults under 65, new 2024 USPSTF recommendation)
- Alcohol misuse screening and brief counseling
- Tobacco cessation counseling and pharmacotherapy
- Obesity screening and intensive behavioral counseling (BMI ≥30)
- Statin therapy preventive counseling (adults 40-75 with risk factors)
- Aspirin preventive therapy counseling (selected adults 40-59)
- Abdominal aortic aneurysm screening (men 65-75 who have ever smoked, one-time)
- Diabetes prevention program (adults with prediabetes)
- Intimate partner violence screening (women of reproductive age)
Women’s Preventive Services at $0
HRSA’s Women’s Preventive Services Guidelines (updated December 2024 for 2026 plan year) require all non-grandfathered plans to cover the following at $0 cost-share — including for transgender, non-binary, and intersex individuals with relevant anatomy.
HRSA Women’s Preventive Services (2026)
- Annual well-woman visit (comprehensive, all ages)
- Breast cancer screening: mammography every 1-2 years starting age 40 (USPSTF), age 35 (CT mandate)
- Breast cancer genetic counseling and BRCA testing for high-risk women
- Breast cancer chemoprevention counseling (high-risk women)
- Cervical cancer screening: Pap every 3 years (21-65), Pap+HPV every 5 years (30-65)
- Contraception: all FDA-approved methods including IUDs, implants, sterilization (no cost-share)
- Emergency contraception (Plan B, ella) prescribed by clinician
- Diabetes screening for women with history of gestational diabetes
- Gestational diabetes screening (24-28 weeks pregnant)
- Folic acid supplementation counseling (reproductive-age women)
- Breastfeeding support, counseling, and equipment (pumps included)
- Lactation consultation (covered for duration of breastfeeding)
- Domestic violence and interpersonal violence screening and counseling
- Osteoporosis screening (women 65+, earlier with risk factors)
- STI counseling and screening for sexually active women
- HIV PrEP (pre-exposure prophylaxis) at $0 — drug + monitoring labs
- Tobacco use screening and cessation
- Urinary incontinence screening (annual, women of all ages — new 2024)
Under ACA contraceptive mandate (clarified by 2022 HHS guidance), insurers MUST cover at least one option in each FDA-approved contraceptive category at $0: barrier (diaphragms, sponges), hormonal (pills, patches, rings), emergency contraception, IUDs (copper + 4 hormonal types), implants (Nexplanon), injection (Depo-Provera), sterilization (tubal ligation), and patient education/counseling. If your insurer denies coverage of a specific brand, file appeal — they must cover a medically appropriate alternative at $0. IUD insertion fees, removal fees, and follow-up visits also covered at $0.
Children & Adolescent Preventive Services
Bright Futures, developed by the American Academy of Pediatrics and HRSA, defines the schedule of preventive services for children and adolescents from birth to age 21. All recommended services are covered at $0 cost-share by all non-grandfathered plans.
Pediatric Bright Futures Services at $0 (2026)
- Newborn screenings (PKU, congenital heart, hearing, hyperbilirubinemia)
- Well-child visits at 14 scheduled ages from birth through age 21
- Developmental and behavioral screening at all well-child visits
- Autism spectrum disorder screening at 18 and 24 months
- Maternal depression screening at well-child visits
- Tobacco, alcohol, drug use assessment (adolescents)
- Depression and suicide risk screening (ages 12-21)
- Anxiety screening (ages 8-18, new 2024 USPSTF)
- Obesity screening and counseling (ages 6+)
- Vision and hearing screening at scheduled ages
- Dental fluoride varnish (birth through age 5)
- Iron deficiency anemia screening (infants)
- Lead screening (ages 12 and 24 months for high-risk areas — includes most CT urban areas)
- Lipid screening (ages 9-11, 17-21)
- Sexually transmitted infection screening (sexually active adolescents)
- HIV screening (adolescents 15+)
- All ACIP-recommended childhood and adolescent vaccines
Vaccines Covered at $0 in 2026
ACIP-Recommended Vaccines (All Ages, $0 Cost-Share)
- COVID-19 vaccine and updated annual boosters (all ages 6 months+)
- Influenza (flu) vaccine — annual, including high-dose for 65+
- RSV vaccine — adults 60+, infants <8 months, pregnant women
- Tdap (tetanus, diphtheria, pertussis) — every 10 years, each pregnancy
- Shingles (Shingrix) — adults 50+
- Pneumococcal (PCV20, PPSV23) — adults 50+ (recommendation lowered from 65)
- HPV vaccine — males and females ages 9-26 (and shared decision-making 27-45)
- Hepatitis A and B vaccines
- MMR (measles, mumps, rubella) — boosters as needed
- Varicella (chickenpox)
- Meningococcal vaccines (adolescents, college students, at-risk adults)
- Mpox vaccine (at-risk adults)
- Childhood vaccine series: DTaP, Hib, polio, rotavirus, hepatitis B, pneumococcal
All major chain pharmacies in Connecticut (CVS, Walgreens, Stop & Shop, Big Y, Costco, Walmart, Rite Aid) participate in most insurance networks for $0 vaccine administration. Pharmacy-administered vaccines avoid the office visit billing trap entirely. Bring your insurance card. For Medicare patients: Part D covers all ACIP vaccines at $0 in 2026 (formerly some required Part B billing). For HUSKY (Medicaid): all ACIP vaccines $0 at participating pharmacies and clinics.
Cancer Screenings Covered at $0 in 2026
Cancer Screening Coverage at $0
- Mammogram: every 1-2 years starting age 40 (USPSTF), age 35 (CT state mandate)
- Colorectal cancer screening: starting age 45 (USPSTF lowered from 50 in 2021)
- Colonoscopy: every 10 years (also covers polyp removal during screening — see billing traps below)
- Cologuard (FIT-DNA): every 3 years
- FIT (fecal immunochemical test): annual
- Cervical cancer: Pap every 3 years (21-65); Pap+HPV every 5 years (30-65)
- Lung cancer LDCT: annually for adults 50-80 with 20+ pack-year smoking history
- Prostate cancer: shared decision-making PSA discussion ages 55-69 (some plans charge for PSA test itself)
- Skin cancer behavioral counseling for fair-skinned adults 6 months to 24 years
- BRCA genetic counseling and testing for high-risk women
- Hepatitis C screening (linked to liver cancer prevention)
Billing Traps That Convert ‘Free’ Care Into Surprise Bills
Roughly 15% of Connecticut patients receive surprise bills for preventive care that should have been $0. The cause is almost always how the visit gets coded. Understanding the top billing traps lets you prevent them at the front desk.
Seven Most Common Preventive Care Billing Traps
- 1. SCREENING → DIAGNOSTIC: Colonoscopy starts as screening ($0) but polyp found and removed — billed as diagnostic ($300-$800 cost-share). Federal rules now require this to be $0 too — but enforcement varies.
- 2. SEPARATE ‘PROBLEM’ VISIT: During annual physical you mention back pain. Provider codes both a wellness visit (free) AND an evaluation/management code (charges your deductible).
- 3. OUT-OF-NETWORK PROVIDER OR LAB: Wellness visit with in-network PCP is $0, but PCP sends labs to OON lab — labs billed separately at full cost-share.
- 4. NON-PREVENTIVE LABS ADDED: Vitamin D, thyroid, testosterone, comprehensive metabolic panel ordered with annual physical — these are diagnostic, not preventive — billed against deductible.
- 5. SCREENING vs DIAGNOSTIC MAMMOGRAM: Screening mammogram is $0; diagnostic mammogram (follow-up after abnormal screening) often charged. CT state law requires $0 for follow-up imaging on CT-regulated plans.
- 6. WRONG ICD-10 CODE: Provider codes for the condition being screened (e.g., ‘family history of cancer’) instead of the screening code (Z12.x) — triggers diagnostic billing.
- 7. AGE/FREQUENCY OUTSIDE GUIDELINE: Annual physical at less than 12-month interval, or screening done before USPSTF-recommended age — not covered at $0.
Until 2022, polyp removal during screening colonoscopy was billed as diagnostic, often costing patients $300-$1,200. The Consolidated Appropriations Act 2023 closed this loophole — polyp removal during screening colonoscopy must now be billed at $0. However, the IRS Notice 2023-37 only requires this for plan years starting AFTER January 1, 2023. Enforcement remains inconsistent. If you receive a bill for polyp removal during screening colonoscopy in 2026, dispute it citing IRS Notice 2023-37 and 86 FR 56582.
Screening vs Diagnostic Coding — The Critical Difference
The single most important concept in preventive care billing is the difference between SCREENING (preventive, $0 cost-share) and DIAGNOSTIC (problem-focused, full cost-share applies). A ‘screening’ test is done on a patient with no symptoms or known condition, to look for hidden disease. A ‘diagnostic’ test is done to investigate or monitor a known symptom or condition.
Examples of Screening vs Diagnostic
- Screening colonoscopy: No GI symptoms, age 45+, routine surveillance → $0
- Diagnostic colonoscopy: Blood in stool, abdominal pain, previous polyps → full cost-share
- Screening mammogram: Annual surveillance, no breast lump → $0
- Diagnostic mammogram: Follow-up of abnormal screening, palpable lump → cost-share (unless CT state law)
- Annual wellness visit: No new complaints, routine preventive → $0
- Problem-focused office visit: Back pain, sinus infection, rash → full cost-share
- Screening Pap smear: Routine cervical cancer screening → $0
- Diagnostic Pap smear: Follow-up of abnormal prior Pap → cost-share
- Screening lipid panel: Routine cholesterol check → $0
- Diagnostic lipid panel: Known high cholesterol, statin monitoring → cost-share
When scheduling: explicitly say ‘I am scheduling a SCREENING [colonoscopy/mammogram/etc.] under my ACA preventive benefits.’ At check-in, again confirm: ‘This visit should be coded as preventive — please verify before billing.’ If a discussion turns into a problem visit, ask the provider: ‘Can we save that issue for a follow-up appointment so this stays as preventive?’ Most providers will accommodate.
Six Real Connecticut Scenarios
Scenario 1: Maria, 47, Hartford — Surprise Colonoscopy Bill
Maria had screening colonoscopy at Hartford Hospital. Two small polyps found and removed. Received $487 bill claiming ‘diagnostic procedure.’ Disputed citing IRS Notice 2023-37 and ACA Section 2713. Hospital re-coded as screening with polyp removal. Bill adjusted to $0. Total dispute time: 28 days.
Scenario 2: David, 52, Stamford — Annual Physical Surprise
Went to PCP for annual physical. Mentioned occasional knee pain. PCP coded BOTH a wellness visit AND a problem-focused E&M code. Received $189 bill for the E&M code. Called billing office, explained he hadn’t requested separate evaluation. Office removed E&M code, billed only wellness visit. Bill went from $189 to $0.
Scenario 3: Jennifer, 38, New Haven — IUD Insertion
Insurer initially denied $850 IUD insertion claim, citing ‘not medically necessary.’ Cited ACA contraceptive mandate requiring $0 coverage for all FDA-approved methods. Internal appeal: APPROVED. Insurer reprocessed at $0. Saved $850.
Scenario 4: Robert, 65, Greenwich — Medicare Wellness Visit
Robert scheduled ‘annual physical’ but Medicare only covers ‘Annual Wellness Visit’ (different code). PCP performed both — billed Annual Wellness Visit ($0) plus problem-focused exam ($142). Called Medicare. Confirmed wellness visit at $0 but problem-focused exam was billable. Future strategy: schedule separate ‘Welcome to Medicare’ physical (one-time) and Annual Wellness Visit only.
Scenario 5: The Patels, Bridgeport — Pediatric Well Visit
Daughter’s well-child visit included $148 charge for ‘developmental screening.’ Per Bright Futures guidelines, developmental screening at well-child visits is covered at $0. Disputed. Pediatrician re-coded as preventive. Bill reduced to $0.
Scenario 6: Lisa, 41, Waterbury — Diagnostic Mammogram After Screening
Screening mammogram showed area of concern; called back for diagnostic mammogram + ultrasound. Received $385 bill. Cited Connecticut CGS § 38a-503f requiring $0 cost-share for follow-up breast imaging after abnormal screening for CT-regulated plans. Insurer reprocessed at $0.
How to Keep Your Preventive Visit at $0
Eight Steps to Avoid Surprise Preventive Care Bills
- 1. Verify provider is IN-NETWORK before booking
- 2. State purpose clearly: ‘I am scheduling a preventive/screening visit under ACA benefits’
- 3. Confirm at check-in that visit will be coded as preventive
- 4. Do NOT raise new health problems during preventive visit — schedule separate appointment
- 5. Ask which labs are ordered and whether they’re preventive or diagnostic
- 6. Confirm labs go to in-network lab (Quest, LabCorp typically in-network)
- 7. Get vaccines at in-network pharmacy (avoids office visit billing entirely)
- 8. Request itemized bill immediately if any charges appear — easier to dispute early
How We Find Your Insurance Helps Maximize Preventive Coverage
Antonucci, Joseph (CT License #21658409) and the team at We Find Your Insurance help Connecticut clients understand their preventive care benefits, identify in-network providers and labs, and dispute incorrectly billed preventive services. We provide written summaries of plan-specific preventive coverage during plan selection and review billing disputes at no charge as part of our brokerage service. Most preventive billing errors are fully reversible within 30-60 days with the right documentation.
Brokerage services are always free. Call 860-919-9663 or visit wefindyourinsurance.com. Office: 1224 Mill Street, Building B, East Berlin, CT 06023. For free advocacy with billing disputes: Office of the Healthcare Advocate at 1-866-466-4446.