Yes, many annual exams are covered at $0, but only when billed as preventive and done in-network under your plan’s rules.
You book a yearly checkup expecting one thing: a preventive visit. Then a bill lands and the “free physical” line feels like a bait-and-switch. Most of the time it isn’t. It’s a mismatch between what you thought you booked and what got billed.
This page spells out what insurers usually treat as preventive, what flips the claim into problem care, and the small choices that reduce surprise charges.
Are Annual Exams Covered By Insurance? What Plans Pay For
Many private plans must pay for a set of preventive services with no cost sharing when you use an in-network provider. That includes common screenings, counseling, and immunizations tied to age and risk. The plain-language summary lives on HealthCare.gov preventive care benefits.
Even on plans with $0 preventive benefits, “annual exam” is not a single, fixed bundle. One office may treat it as counseling plus screening orders. Another may add extra labs by default. The codes on the claim tell the insurer what happened, not the words used at check-in.
When a plan says “no cost sharing,” it usually means no copay and no coinsurance for that preventive service. It also often means the deductible doesn’t apply. Network rules still matter. A preventive service done out-of-network can be charged as if it were any other visit.
| Service You Might Get | Often $0 In-Network | When Charges Are Common |
|---|---|---|
| Preventive office visit (annual physical) | Yes, on many ACA-compliant plans | Out-of-network or billed as problem care |
| Basic measurements and screening questions | Usually yes | Charges usually tie to a separate problem code |
| Vaccines recommended for your age | Often yes | Out-of-network clinic or non-covered vaccine |
| Cholesterol or diabetes screening | Often yes | Ordered for symptom follow-up or monitoring |
| Pap test/HPV screening | Often yes | Repeat testing outside your plan’s interval |
| Mammogram or colon cancer screening | Often yes | Diagnostic imaging after symptoms or findings |
| Depression, tobacco, alcohol use screening | Often yes | Charges if billed as therapy or treatment work |
| Extra labs (vitamin D, hormone panels) | Sometimes | Frequently billed as diagnostic or not covered |
| EKG, imaging, specialist testing | Sometimes | Often treated as diagnostic with cost sharing |
Use that table as a map. Your bill usually comes from one of three places: your plan type, network rules, or the codes attached to the visit and any labs. You can control all three with a little prep.
Annual Exam Insurance Coverage By Plan Type
Most Marketplace And Employer Coverage
If your plan follows Affordable Care Act preventive rules, many screenings are tied to national recommendations. One driver is the U.S. Preventive Services Task Force list of A and B grade services on the USPSTF A and B recommendations page. Plans still apply network and timing rules, so the same test can be $0 for one person and billed for another if the plan’s conditions aren’t met.
Plan design still matters. Some HMOs require you to use a primary care clinician for preventive visits. Some PPOs allow broader choice but still price out-of-network care differently. If your plan has a “preventive visit” benefit line, look for any note about primary care only.
Older Plans And Non-ACA Plans
Some older plans keep older benefit designs. Some short-term or fixed-indemnity plans pay a set amount per service. Many of these plans do not waive cost sharing for preventive care in the same way. If you don’t see preventive care language in your plan documents, assume you’ll owe something and ask the clinic for a cash quote before you go.
Medicare And Medicaid
Medicare and Medicaid use different benefit terms than private plans. Medicare Part B includes a yearly wellness-style visit for eligible members, and Medicaid benefits vary by state. The lesson is the same: the name on the clinic schedule matters less than the benefit language in your plan and the codes on the claim.
What To Ask Your Insurer In Five Minutes
If you can spare one phone call, you can avoid most surprises. You don’t need to ask for a “price.” Ask which benefit applies and what conditions must be met.
- “Does my plan pay for a preventive annual physical with no cost sharing when in-network?”
- “Does the plan require primary care for that benefit?”
- “If a problem visit code is billed the same day, does it trigger a copay or deductible?”
- “Which labs count as preventive screening for me this year?”
- “Which labs must be done at a preferred lab site to stay in-network?”
Ask the representative to point you to the exact benefit name in your plan document. Write down that name and the call reference number, then keep it with your EOB.
What Turns A Preventive Visit Into A Bill
Most surprise charges happen when the appointment becomes a mix of prevention and problem care. You mention a new symptom, the clinician evaluates it, and a problem-oriented code gets added to the claim. That extra code triggers your normal cost sharing.
Two Visit Types Can Be Billed On One Day
Clinics can bill a preventive visit and a problem visit on the same date when both happened. That isn’t automatically wrong. It’s how billing separates “screening and counseling” from “evaluation and treatment.”
Codes You May See On Your Claim
Many claims list a preventive medicine visit code (often in the 99381–99397 range) when the appointment is preventive. Problem visit codes often fall in the 99202–99215 range. Labs and imaging have their own code sets. The numbers aren’t something you need to memorize, but they help you spot whether the claim was processed as preventive, problem care, or both.
Labs Follow The Diagnosis Code
A lab order can be screened as preventive or processed as diagnostic depending on the diagnosis code attached. The same blood test can be $0 in one context and subject to the deductible in another. If you’re billed for a lab you expected to be screening, ask which diagnosis code was sent with the order.
Follow-Up After A Finding Is Often Diagnostic
A screening that finds something often leads to follow-up tests. Plans commonly treat that follow-up as diagnostic care. That’s why “my screening was free” and “my follow-up cost money” can both be true.
Steps That Keep Your Annual Exam In The Covered Lane
Before You Book
- Confirm in-network status. Verify the clinician and the facility, not only the clinic brand.
- Ask how they label the appointment. Use the words “preventive visit” and ask if a separate problem code is likely.
- Ask where labs are sent. Out-of-network labs create bills even when the clinic is in-network.
- Ask what “routine labs” means. Some offices bundle extras into a default panel.
During The Visit
Bring questions, then separate them into two lists. List one is prevention: vaccine status, screening timing, family history updates, sleep, tobacco, alcohol, and safe activity. List two is problems: pain, a new lump, a rash you want treated, mood symptoms, or medication changes.
If you want both lists handled in one sitting, that can still work, but it can also add a problem-visit charge. Another option is a second appointment for problems so the preventive visit stays clean.
If the clinician suggests an extra test, ask two quick questions: “What is the reason for this test?” and “Is it a screening test or follow-up?” That keeps the visit aligned to your goal and gives you a chance to price the test.
After The Visit
Read your Explanation of Benefits (EOB). It shows the codes, how the claim was categorized, and what you owe. If the visit was scheduled as preventive and the EOB shows only problem care, ask the billing office for a coding review and resubmission.
People often type “are annual exams covered by insurance?” right after a surprise charge. Your EOB is the fastest place to see what the insurer thought your visit was.
Common Reasons You Get Charged And What To Do
The fix is usually one clear question. Start with the claim details, then move to the office that can change the code or reroute the lab.
| Why You Got A Bill | Question To Ask | Next Move |
|---|---|---|
| Problem visit code added | “Was a preventive code billed too?” | Request a coding review if prevention was the purpose |
| Symptom evaluation during the visit | “Which services were billed for symptom care?” | Split preventive and problem visits next year |
| Lab processed out-of-network | “Which lab or facility was used?” | Set a preferred in-network lab before the next visit |
| Screening repeated early | “What interval does my plan use?” | Align timing with plan rules unless medical notes justify it |
| Screening led to diagnostic follow-up | “Is the follow-up coded as diagnostic?” | Ask for an estimate before scheduling follow-up tests |
| Non-ACA plan with limited prevention | “Does this plan waive cost sharing for preventive visits?” | Ask for a cash price quote, then compare clinics |
| Preferred provider rule not met | “Does my plan require primary care for $0 prevention?” | Book the next annual exam with an eligible provider |
High-Deductible Plans And Hidden Add-Ons
High-deductible plans often waive the deductible for preventive services, but add-on testing can still fall under the deductible. If you request extra panels out of curiosity, expect a charge unless your plan lists them as preventive. The same goes for imaging that’s ordered to clarify a symptom.
If you want a cleaner estimate, ask the clinic for the lab and test codes they plan to order, then call the insurer and ask how those codes process under your plan. It takes a few minutes and can save you a headache later.
Quick Checklist For A No-Surprise Annual Exam
- Verify the clinician, facility, and lab are in-network.
- Book the appointment as a preventive annual exam.
- Ask if the office bills a separate problem code when symptoms are handled.
- Keep prevention questions and problem questions on separate lists.
- Ask “screening or follow-up?” before extra tests are ordered.
- Read the EOB, then match every bill to it.
When Charges Can Still Happen
Out-of-network care can override preventive benefits. A plan that doesn’t follow ACA preventive rules can charge cost sharing for the visit itself. Follow-up tests after an abnormal screen are often diagnostic, so they may cost money even when the screening was $0.
If you’re still asking “are annual exams covered by insurance?” after you read the EOB, look at your plan’s preventive benefits list and network directory. Those two pages usually settle it.