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Starting December 31, 2025, group health plans and insurers must fully cover additional breast cancer imaging and testing, as well as patient navigation services for breast and cervical cancer screenings, without cost sharing.
Preventative Care Mandate
The Affordable Care Act (ACA) mandates that non-grandfathered health plans cover recommended preventive services without cost-sharing when provided by in-network providers. These recommended preventative care services are:
- Evidence-based services with top ratings from the U.S. Preventive Services Task Force,
- Routine immunizations for all ages recommended by the Advisory Committee on Immunization Practices, and
- Health Resources and Services Administration (HRSA) supported preventive care and screenings for infants, children, adolescents, and women.
The ACA's preventive care guidelines are updated periodically, with changes taking effect for plan years starting one year after issuance.
New Guidelines
HRSA guidelines mandate that health plans cover mammography screenings for women at average risk for breast cancer, starting between ages 40 and 50, at least every two years, or annually. As of December 30, 2024, these guidelines now include additional imaging to complete screenings. By 2026, plans must cover initial mammography and any necessary additional imaging or pathology evaluations without cost sharing.
Starting in 2026, most health plans must offer personalized navigation services for breast and cervical cancer screenings, including assessments, healthcare access, referrals, and education.
Employers should review their preventative care coverage in advance of the 2026 plan year to determine if changes must be made. Coverage changes should be communicated to employees through an updated Summary Plan Description or a Summary of Material Modifications. Download the bulletin for more details.
National Insurance Services is not a law firm and no opinion, suggestion, or recommendation of the firm or its employees shall constitute legal advice. Readers are advised to consult with their own attorney for a determination of their legal rights, responsibilities and liabilities, including the interpretation of any statute or regulation, or its application to the readers’ business activities.
