As October is Breast Cancer Awareness Month, employers that sponsor group health plans should be aware of the expanded breast cancer screening benefits that are scheduled to take effect in 2026.
Background
The ACA requires non-grandfathered group health plans (whether fully insured or self-insured) to cover certain preventive care in-network without cost-sharing (including deductibles, copayments, or coinsurance). The required covered care includes services given an “A” or “B” rating from the U.S. Preventive Services Task Force (USPSTF), vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), and preventive care and screenings for children and women recommended by the Health Resources and Services Administration (HRSA).
If there are changes in recommendations or guidelines, plans generally must provide coverage for plan years that begin one year after the change. For example, a change recommended in December 2024 would take effect in plan years beginning in 2026. Specific information about recommendations and guidelines is available on the healthcare.gov website: preventive health services | healthcare.gov. The agencies have indicated this site will be updated to reflect the date of adoption of a recommendation so sponsors and insurers will know when coverage is required.
2026 Changes
Updated HRSA Women's Preventive Services Guidelines will broaden the range of breast cancer screening benefits that are covered as preventive care. Currently, ACA guidelines require group health plans to cover routine screening mammograms for women at average risk of breast cancer starting at age 40, at least biennially and as frequently as annually. Effective for plan years beginning in 2026, the coverage must also include additional imaging services (e.g., ultrasounds or MRIs) when medically indicated, and pathology services (e.g., a needle biopsy), if necessary to complete the screening process for malignancies or address findings on the initial mammography.
Furthermore, new HRSA guidance requires coverage (without cost-sharing) of patient navigation services for breast and cervical cancer screening and follow-up to increase use of screening recommendations based on the patient's need for such services. Navigation services would include patient assessment and care planning, referrals to supportive resources (e.g., transportation, language translation, and social services), patient education and coaching, as well as healthcare access and system navigation. These services should be individualized to the patient and can be provided in person and/or virtually. According to the HRSA, navigation services have proven to lead to earlier cancer detection, improved screening rates, and treatment outcomes.
The 2026 HRSA updates are in addition to existing USPSTF-recommended preventive services, which include breast cancer susceptibility gene (BRCA) screening, genetic counseling, and testing, if appropriate for a woman as determined by her healthcare provider (e.g., based on a prior breast cancer diagnosis or family history associated with an increased risk of BRCA-related cancer). The USPSTF guidelines also include coverage of risk-reducing prescription medications (e.g., tamoxifen) for certain women at increased risk for breast cancer, when prescribed by clinicians.
Employer Takeaway
Employers should be aware of the upcoming expanded breast cancer screening and coverage changes in 2026 and consult with their carriers, TPAs, and other service providers regarding necessary updates to plan systems, documents, and participant communications to implement these requirements. Employers may also want to inquire regarding any potential budgetary impact resulting from the expanded coverage recommendations.
Additionally, employers should monitor for further updates to preventive services guidelines generally, since there have been recent staffing changes at the agencies that make the recommendations and pending litigation challenging aspects of the ACA preventive services mandate. We will report relevant developments in Compliance Corner.
Read the full expansion of changes here: Update to the Health Resources and Services Administration-Supported Women's Preventive Services Guidelines