cost guide · 9 min read
Annual checkup cost: often $0 under the ACA, and 4 things that can add a bill
The free-checkup rule, the Medicare version, and how coding, labs, networks and plan type decide whether a bill follows the visit.
By ThriveBrook editors · Updated October 2026
Most private health plans in the US have to pay for a yearly preventive checkup in full, with no copay, no coinsurance and no deductible, as long as the doctor is in your plan’s network. That rule comes from the Affordable Care Act. The Supreme Court left it standing on June 27, 2025, when it ruled 6-3 in Kennedy v. Braidwood Management.
People still open a bill after a checkup they thought was free. Before you book yours, call the member services number on the back of your insurance card and ask one question: “Is my annual preventive visit covered at $0 with this doctor?” The answer, plus the four triggers below, decides whether you pay nothing.
What a checkup costs, from $0 up
The preventive part of the visit should cost you $0 in network. Anything else the doctor does that day gets billed at your plan’s normal rates, and those vary a lot.
KFF, a health policy research group, surveys employer health plans every year. Its 2025 survey found that 88% of workers with single coverage have a deductible, and the average one is $1,886. Until you’ve met it, you usually pay the plan’s full negotiated price for any care outside the free list.
After the deductible, the same survey puts the average copay for a primary care visit at $27. Plans that use coinsurance charge 19% of the bill on average.
Medicare runs on its own numbers. The yearly wellness visit costs nothing if your doctor accepts assignment, which means taking Medicare’s approved amount as full payment. Extra services fall under Part B, which has a $283 deductible in 2026 and then 20% coinsurance on most care.
Your own deductible is printed on your plan’s summary of benefits and coverage, a standard form every plan must give you. Look it up before the visit. Until you’ve spent that much in a year, a surprise line on the bill is usually yours to pay in full.
Who writes the free list
Your insurer doesn’t pick what’s free. Four federal sources do: screenings and counseling rated A or B by the US Preventive Services Task Force, vaccines recommended by the CDC’s vaccine advisory committee, and two sets of guidelines from the Health Resources and Services Administration, one for women and one for children.
For adults, the task force list includes blood pressure checks from age 18 and depression screening. It also lists cancer screenings that start and stop at set ages.
Your doctor decides which screenings fit you, based on your history and risk. Find your age on the chart, then ask at the visit which ones are due this year.
Hepatitis C screening runs from age 18 to 79, and cervical screening for women runs from 21 to 65.
Diabetes screening covers adults who are overweight from 35 to 70. Women get a breast scan once every 2 years from 40 to 74, and colorectal screening for everyone runs from 45 to 75.
The yearly lung scan covers adults aged 50 to 80 who have a smoking history of at least 20 pack-years. One pack-year means a pack a day for a year.
The list can change. The Braidwood ruling rests on the health secretary’s power to appoint and remove task force members at will. In June 2025 the secretary replaced all 17 members of the CDC’s vaccine committee. The $0 rule stands, but what sits on the list is up to whoever holds those seats.
Free and billed, side by side
One visit can produce a $0 line and a billed line on the same claim. This is how the split usually falls.
| At the visit | Usually $0 in network | Can add a bill |
|---|---|---|
| The exam | Yearly preventive visit | Same-day visit for a new or ongoing problem |
| Blood pressure | Screening, adults 18 and older | Follow-up to manage high blood pressure |
| Blood work | Screening tests on the federal list for your age and risk | Tests outside the list, or tests to check a symptom |
| Colon cancer | Screening colonoscopy, ages 45 to 75 | On Medicare, 15% coinsurance if a polyp is removed |
| Medicare | Yearly wellness visit, once every 12 months | A routine physical exam, which Medicare doesn’t cover |
Sources: the task force’s A and B list, Medicare’s coverage pages and the American Cancer Society’s guide to screening coverage.
Most of the right-hand column comes down to one difference. Screening looks for something nobody has found yet, while care for a new or known problem is billed as ordinary medicine. When a claim shows a right-hand item, the charge is usually correct if the visit was coded that way. The four sections below explain how each one gets there.
A new problem, a second bill
Of the four triggers, this one is the easiest to set off by accident. You mention knee pain, ask about a new rash, or want a refill for a condition you already treat, and the doctor handles it in the same visit. The office then bills two things: the preventive exam and a problem visit, flagged as a separate service on the same day.
If you haven’t met your deductible yet, that second line is billed at the plan’s full negotiated price for an office visit.
Don’t hold back a symptom to dodge the charge. A new problem deserves the doctor’s time, and a copay near $27 is a fair price for it. You can ask at check-in, “If I bring up my knee, will that be billed as a separate visit?” You can also book a second appointment for an ongoing condition so the checkup stays a checkup.
Medicare has its own version of this. The yearly wellness visit is a conversation about prevention and a plan for the coming year, and Medicare’s coverage page is blunt about what it leaves out.
It isn’t a routine physical exam.
If the doctor adds tests or services during the visit, the same page says you may owe coinsurance and the Part B deductible. For extras Medicare doesn’t cover at all, you may have to pay the full amount.
Lab tests outside the list
Blood work is where coding sets the price. A cholesterol test ordered as a screening for your age counts as preventive. The same test ordered to track a condition you already have is diagnostic, and your plan bills it like any other lab work. Tests the federal list doesn’t name at all usually go to your deductible.
Colon cancer screening shows how one procedure can switch categories halfway through. Under Medicare, a screening colonoscopy is free. If the doctor removes a polyp during it, the American Cancer Society notes that you owe 15% coinsurance, though no deductible.
Private plans have a different gap. The society says some insurers treat the colonoscopy that follows a positive at-home stool test as diagnostic, so your usual deductible and copay apply.
Before the blood draw, ask which tests are screening and which are for something else.
An out-of-network doctor or lab
The $0 rule covers in-network care only. HealthCare.gov, the federal marketplace site, says preventive services are covered at no cost “when provided by an in-network medical provider.”
Your doctor can be in network while the lab isn’t. If the office sends your blood to an outside lab, a screening that should have cost nothing can come back as an out-of-network charge.
A doctor who was in your network last year may not be this year either, so call the number on your card to check again after any change of plan or job.
Plans the rule doesn’t reach
Two kinds of coverage can skip the $0 rule entirely.
Grandfathered plans are employer or individual plans that already existed on March 23, 2010, the day the Affordable Care Act became law, and haven’t changed much since. They have to say they’re grandfathered in their plan materials.
Short-term plans aren’t ACA coverage at all, so they don’t have to cover preventive care. A 2024 federal rule capped them at 4 months in total, renewals included. On August 7, 2025, the Labor, Treasury and Health and Human Services departments said they would not prioritize enforcing that cap while they write a new rule. You may see short-term plans offered for longer than 4 months as a result.
Search your plan documents for the words “grandfathered” and “short-term.” If either one shows up, ask the insurer what a checkup will cost before you book.
If a bill shows up anyway
Don’t pay a checkup bill the day it arrives. Wait for your insurer’s explanation of benefits, the statement that shows what the doctor billed, what the plan paid and what you owe, and lay the two side by side.
If the visit appears as a regular office visit with no preventive line, call the doctor’s billing office first. Ask whether the visit was coded as preventive and, if you raised no new problem, whether it can be billed again with the right code.
If the office stands by the coding and you still disagree, file an appeal with your plan. HealthCare.gov’s guide to appeals gives you 180 days from the denial notice to file, and for care you’ve already received, the plan must decide within 60 days. If it still says no, plans covered by the Affordable Care Act must let you ask for an outside review by an independent reviewer.
Book it this week
Choose the doctor, confirm that the office and its lab are both in your network, and book a preventive visit for sometime in the next month. Write down anything new you plan to mention, so you remember to ask at check-in how it will be billed. Then pick up your insurance card, turn it over and dial the member services number printed on the back.