Annual Physicals and Preventive Care in a DPC Practice, What to Include and How Insurance Fits

What should an annual physical in a DPC practice include?

An annual physical in a direct primary care practice is a membership visit, so the practice sets its contents rather than a billing code, and the strongest public checklist to build it around is the US Preventive Services Task Force list of grade A and B services. Screening that needs outside imaging or procedures can run through the member's insurance, where most private plans must cover recommended services with no cost sharing when an in-network provider delivers them. The evidence is mixed in a useful way, since general health checks have not been shown to lower deaths but have been linked to more preventive services completed and better risk factor control, which points toward a visit shaped by what each member is actually due for.

This guide is written for physicians and owners running a practice. It covers operations and the rules around them, not advice for any individual patient. Recommendations and coverage rules change, so everything below reflects each source as we read it on November 5, 2026, and the links go to the bodies that set them.

What is on the USPSTF A and B list for adults?

The Task Force gives a grade A when it has high certainty that the net benefit is substantial, and a grade B when it has high certainty of a moderate net benefit or moderate certainty of a moderate to substantial one. Its suggestion for both is to offer or provide the service. The full list had 54 rows when we checked it, covering adults, pregnancy, children and adolescents.

This table pulls out most of the rows for nonpregnant adults, with the release dates the Task Force lists. The full list also has intensive, multicomponent behavioral weight loss interventions at a BMI of 30 or higher, diet and activity counseling with cardiovascular risk factors, STI counseling for adults at increased risk, skin cancer counseling for people with fair skin through age 24, folic acid for anyone who could become pregnant, BRCA risk assessment and risk-reducing breast cancer medication. Each row has conditions a table cannot hold, so read the linked recommendation before writing a protocol.

The list's own status is worth knowing. The newest date on it was June 2025 when we checked. On September 17, 2026, HHS announced eight new members joining the eight already serving. Reuters reported that day that the panel had last met a year earlier, and AHRQ says it then convened on September 29 and 30, 2026, when the new members completed orientation and all 16 were sworn in. The Supreme Court upheld the Task Force's structure in June 2025, and it found that the HHS Secretary can remove members at will and review their recommendations, so a protocol built on this list deserves a recheck on a set schedule.

What the Task Force does not recommend for routine use

The same body grades several tests a practice may want to decide on deliberately. It recommends against ECG screening in asymptomatic adults at low risk of cardiovascular events (grade D) and calls the evidence insufficient for those at intermediate or high risk. It calls the evidence insufficient for vitamin D screening and for thyroid screening in asymptomatic nonpregnant adults, which means it could not weigh benefit against harm, not that it found harm. For PSA-based screening, it calls the decision in men 55 to 69 an individual one, after a chance to discuss benefits and harms (grade C), says clinicians should not screen men who do not express a preference, and recommends against it in men 70 and older (grade D). The Task Force lists this topic as being updated. Members may still ask for these tests, and the grades give the physician and patient a shared starting point for that conversation.

How can a DPC practice structure the annual visit?

We could not find a federal rule or a national standard that sets the contents of an adult annual physical, so the practice decides. A visit built around the list above might run in this order:

• A pre-visit questionnaire covering history changes, family history, medications, tobacco, alcohol and drug use, mood, safety and falls for older members.
• A check of what is due, prepared before the patient arrives, so the visit starts from known gaps.
• Routine measurements, including height, weight and blood pressure.
• The conversation the patient came for, plus counseling on whatever the screening raised.
• Orders and referrals for what is due, and the labs the history calls for.
• A written plan that names what is due, when and who is arranging it.

Three public outlines help with particular groups. For older members, Medicare's description of the yearly wellness visit lists a health risk assessment, routine measurements, a review of history and prescriptions, a cognitive assessment, a substance use risk review, an offer to discuss advance directives and a written screening plan. For women, the HRSA-supported guidelines call for at least one preventive care visit per year from adolescence on. Children have their own schedule under the HRSA-supported Bright Futures guidelines, which we cover in our pediatric DPC guide, and vaccines are in how to offer them in a DPC.

The hands-on exam draws the most skepticism in the guidance we read. The Society of General Internal Medicine's Choosing Wisely page links a 2022 revision that says not to perform routine annual checkups unless patients are likely to benefit, to base their frequency on individual risk factors and preferences, and not to conduct comprehensive physical exams or routine lab testing during them. The same document says patients who are well connected to primary care and up to date on preventive care are unlikely to benefit from a yearly checkup. A member who wants a hands-on exam can still have one, and a membership visit has room for it. Spelling out in the membership agreement which labs are included prevents surprises, and our guide to dispensing and labs in DPC covers the rules around them.

How does ACA preventive coverage apply when a DPC member has insurance?

Section 2713 of the Affordable Care Act requires most private plans and Medicaid expansion programs to cover four sets of preventive services without cost sharing, namely USPSTF grade A and B services, vaccines recommended by ACIP, and HRSA-supported guidelines for women and for children. HealthCare.gov adds that this applies even before the deductible is met, though it says the services are generally free from an in-network provider and that zero cost is not guaranteed in every case. A grandfathered plan sits outside the rule.

For a DPC practice, the network language in 45 CFR 147.130 is the part that matters. A plan with a network does not have to pay for these services from an out-of-network provider, and it can charge cost sharing if it does, unless it has no in-network provider who can deliver the service. Since a DPC visit is paid by the membership and not billed to the plan, this rule does not require the plan to pay for it, and the member's no-cost benefit stays available for services delivered in network.

That leaves a clean division a practice can explain to members:

A few details in the rule and its guidance come up in practice:

• Who wrote the order. The regulation's text does not address the ordering clinician, so whether a plan accepts an order from a physician outside its network is a question for that plan. See also what insurance to pair with DPC.
• Follow-up colonoscopy. The federal agencies' FAQ Part 51 says plans have to cover a colonoscopy after a positive stool test without cost sharing, because the Task Force treats it as needed for the screening benefit, and it restates that items integral to the service, such as anesthesia for a preventive colonoscopy, are covered too.
• Breast screening. The Task Force's list carries a footnote saying HHS uses its 2002 breast screening recommendation for coverage purposes, so coverage does not track the 2024 clinical wording exactly.
• Frequency and timing. The regulation lets plans use reasonable medical management on frequency, method and setting where the recommendation does not specify them. Plans also have until plan years starting a year after a recommendation is issued, so a new row on the list may not be a covered benefit yet.

Members on an HSA-eligible plan can keep contributing while they hold a membership that qualifies, and our HSA guide covers what makes one qualify.

How Medicare is different

Medicare draws its own line. CMS says a routine physical exam is not covered and the patient pays all of it, while Part B covers the yearly wellness visit once every 12 months at no cost when the provider accepts assignment. Medicare.gov says the wellness visit is not a routine physical. A member new to Part B starts differently, because CMS lists an initial preventive physical exam covered within 12 months of starting Part B, and Medicare.gov says the first wellness visit can't fall within 12 months of Part B enrollment or that exam.

If a physician has opted out, Medicare will not pay for that physician's services, so a member who wants the wellness visit paid would get it from a clinician who bills Medicare. An opted-out physician who has not been excluded, whose Medicare enrollment has not been revoked and who is not paid, directly or indirectly, for what they order, prescribe or refer, except as 42 CFR 405.440 allows, can still order tests and refer under 42 CFR 405.425, with a Medicare-covered service still covered when a provider who bills Medicare delivers it. The details are in our Medicare opt-out guide and our guide to DPC for seniors on Medicare.

How should a DPC handle screening referrals?

Four of the rows in the adult table need imaging and one can need a procedure, so these referrals are where a preventive item can quietly stop moving. Each one has steps outside the practice's walls, and none of the tools involved was built to tell the practice when one stalls.

For a member with insurance, the referral note can state the indication as screening, since the no-cost rule applies to recommended preventive services, and the member can confirm the facility is in network. For a member without insurance, the practice can share any self-pay options it has vetted, and our guide to cash-price imaging for DPC covers how to build that list. In both cases, the order should say where the report goes, because a screening test the physician never sees has not finished its job. Tracking works like any other referral, with the closed loop in our specialist referral tracking workflow, and our guide to getting outside records covers a report that does not arrive.

How do you track which members are due?

A due list works best per service and not per visit, since what members need comes due on different schedules. For each service, the record needs:

• The rule for who qualifies, with a link to the recommendation it came from.
• The date it was last done and how the practice knows, including results from outside the practice.
• The next due date, based on the interval in that recommendation.
• A status of due, declined, ordered, scheduled, resulted or reviewed.
• One person who owns moving it forward.

Declined deserves its own status with a date, so a member's choice is recorded and raised again at a sensible interval. Reviewed is separate from resulted because a report in the chart is not the same as a physician having read it and told the patient. Our preventive care gap tracking guide lays out the routine in detail, with metrics to watch alongside it.

Time is the reason this list is worth building. A simulation in the Journal of General Internal Medicine estimated that a primary care physician would need 14.1 hours a day for guideline-recommended preventive care alone on a modeled panel of 2,500 adults, and 2.0 hours a day with team-based care. Those figures are modeled and do not describe DPC, where AAFP's 2026 survey, with 53% of respondents practicing in DPC, reports a much smaller average panel of 504, and we did not rescale them.

What does the evidence say about annual physicals?

The largest body of evidence looks at general health checks, meaning multiple tests offered to people who do not feel ill. A Cochrane review published in 2019, with searches through January 2018, found 17 randomized trials, 15 of which reported results on 251,891 participants. Health checks had little or no effect on total mortality (risk ratio 1.00, 95% CI 0.97 to 1.03) and cancer mortality (risk ratio 1.01, 95% CI 0.92 to 1.12), both rated high certainty, and probably little or no effect on cardiovascular mortality, rated moderate certainty. The authors concluded that general health checks are unlikely to be beneficial.

Two limits matter for a membership practice. The trials compared invitations to health checks with no invitations in the general public and excluded geriatric trials. Five of them ran in general practice, and one of those added yearly lifestyle talks with the patient's physician and, the review says, found no effect, so as we read it only a small part of this evidence speaks to an annual visit inside an ongoing relationship with a physician. The Cochrane authors also propose that part of the missing effect may come from primary care physicians already identifying and acting on risk when they see patients for other reasons.

A 2021 review in JAMA, covering 19 randomized trials and 13 observational studies through March 2021, agreed on the hard outcomes, finding no association with reduced mortality or cardiovascular events. It also found associations with more recognition and treatment of chronic disease, better risk factor control, more uptake of preventive services and better patient-reported outcomes. One observational example is colorectal screening at 69% among people who attended a Medicare wellness visit and 60% among those who did not, which cannot prove the visit caused the difference. The authors concluded that primary care teams may reasonably offer health checks, especially to groups at high risk of overdue services, uncontrolled risk factors, low self-rated health, or poor connection or inadequate access to primary care.

We searched for studies of annual visits or screening completion inside DPC practices and did not find any, so nothing here shows that a DPC annual visit performs better or worse than any other kind.

Putting it together

A practice can land on a simple design from all this. Offer the annual visit as a set moment to catch up on what is due, build its contents from the graded list instead of a fixed panel, send the imaging and procedures through the member's coverage when that serves them, and keep one list of who is due that survives between visits.

The harder part is that the work lives across tools, with the due date in the EHR, the report in a fax inbox and the reminder in a messaging app, and none of them was built to talk to the others. Tabflows is a dedicated tech team that connects the tools a clinic already uses, so screening follow-ups get done and the patient's context sits in one place. Good next reads are our guide to starting a DPC and chronic disease management in a DPC.