Health Plans Must Expand Coverage for Breast Cancer Screening for 2026

Effective for plan years beginning after Dec. 30, 2025, group health plans and health insurance issuers must expand their first-dollar coverage for preventive care for women to include additional breast cancer imaging or testing that may be required to complete the initial mammography screening process. In addition, health plans and issuers must cover patient navigation services for breast and cervical cancer screening without cost sharing.

HIGHLIGHTS

• Effective for the 2026 plan year, most health plans will be required to expand their first-dollar preventive care coverage to include additional breast cancer screenings.
• Patient navigation services for breast and cervical cancer screening must also be covered without cost sharing.
• Employers should review their preventive care coverage in advance of the 2026 plan year to determine if changes must be made.
• In general, coverage changes should be communicated to participants through an updated Summary Plan Description (or a Summary of Material Modifications).

Preventive Care Mandate

The Affordable Care Act (ACA) requires non-grandfathered health plans and issuers to cover a set of recommended preventive services without imposing cost-sharing requirements, such as deductibles, copayments or coinsurance, when the services are provided by in-network providers. The recommended preventive care services covered by these requirements are:

• Evidence-based items or services with an A or B rating in recommendations of the U.S. Preventive Services Task Force;
• Immunizations for routine use in children, adolescents and adults recommended by the Advisory Committee on Immunization Practices;
• Evidence-informed preventive care and screenings in guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents; and
• Other evidence-informed preventive care and screenings in HRSA-supported guidelines for women.

The ACA’s preventive care guidelines are periodically updated based on new medical research and recommendations. Updated guidelines generally take effect for plan years beginning one year after the date the updated guideline is issued.

New Guidelines

The current HRSA-supported guidelines require health plans and issuers to cover, without cost sharing, mammography screening for women at average risk for breast cancer at least biennially and as frequently as annually, beginning no earlier than age 40 and no later than age 50. On Dec. 30, 2024, HRSA updated its breast cancer screening guidelines to include additional imaging to complete the screening process. Beginning in 2026, most health plans and issuers must cover, without cost sharing, the initial mammography plus any additional imaging (e.g., MRI, ultrasound or mammography) or pathology evaluation required to complete the screening process for malignancies.

In addition, beginning in 2026, most health plans and issuers must provide individualized patient navigation services for breast and cervical cancer screening and follow-up. These services must include person-centered assessment and planning, health care access and health system navigation, referrals to appropriate support services (e.g., language translation, transportation and social services) and patient education.

Contact SSG if you would like to speak to a Benefits Advisor about reevaluating your company benefits.