Health Plans Must Expand Breast Cancer Screening and Navigation Coverage in 2026

On December 30, 2024, the Health Resources and Services Administration (HRSA) issued updated preventive care guidelines requiring non-grandfathered group health plans to expand their no-cost coverage for breast cancer screening and related services. As a result, beginning with plan years that start on or after December 30, 2025, affected plans must cover additional imaging or testing needed to complete the initial mammography screening process and patient navigation services for breast and cervical cancer screening—all without cost sharing.

What’s Changing?

Under the updated HRSA-supported guidelines:

• Plans must cover, without cost sharing, additional breast imaging (e.g., MRI, ultrasound or mammography) and pathology evaluation when needed to complete the screening process for malignancies following an initial mammogram.
• Plans must also provide individualized patient navigation services for breast and cervical cancer screening and follow-up. These services include person-centered assessment and planning, healthcare access and health system navigation, referrals to appropriate support services (e.g., language translation, transportation, social services), and patient education.

These requirements apply to non-grandfathered group health plans and health insurance issuers, starting with the plan year that begins one year after the guideline’s publication—in this case, for plan years beginning on or after December 30, 2025. Calendar year plans will need to comply beginning on January 1, 2026.

Background: Preventive Care Requirements Under the ACA

The Affordable Care Act (ACA) requires non-grandfathered health plans to cover certain preventive services without imposing cost sharing as long as the services are delivered by in-network providers. These services include:

• Evidence-based items or services rated A or B by the U.S. Preventive Services Task Force
• Routine immunizations recommended by the Advisory Committee on Immunization Practices
• Preventive care and screenings for infants, children, and adolescents supported by HRSA
• HRSA-supported preventive care and screenings specifically for women

These guidelines are updated periodically to reflect current clinical recommendations. When HRSA or other applicable agencies issue a new or revised guideline, plans generally have until the first day of the plan year one year later to implement the change.

What Employers Should Do

Employers should review their plan’s preventive care coverage before the 2026 plan year to determine whether updates are needed. In most cases:

• Coordinate with your insurance carrier or third-party administrator to confirm compliance with the new guidelines.
• Communicate any required changes to participants through an updated Summary Plan Description (SPD) or a Summary of Material Modifications (SMM).

If your organization sponsors a non-grandfathered group health plan, these changes will likely apply to you. Ensuring timely updates now can help prevent compliance issues later.

Reach out to your Hylant representative for further information. Don’t have one? Contact us here.

The above information does not constitute advice. Always contact your employee benefits broker or trusted advisor for insurance-related questions.