Group health plans and insurers are required to cover additional breast imaging and pathology services and patient navigation services for plan years beginning on or after January 1, 2026. Sponsors of non-calendar-year plans must comply with the guidelines for the first plan year beginning on or after December 30, 2025.

Background on the ACA’s preventive services mandate

The ACA’s preventive services mandate requires non-grandfathered group health plans and insurers to cover certain preventive services recommended by three entities with no cost-sharing on an in-network basis:

• The United States Preventive Services Task Force, which gives “A” or “B” ratings for specific evidence-based items and services
• The HRSA, which has guidelines regarding preventive care and screening for infants, children, adolescents and women
• The Advisory Committee on Immunization Practices, which issues recommendations on immunizations

The ACA’s preventive care guidelines are periodically updated or modified. Plans must comply with the updated guidelines in plan years beginning one year after the date the updated guideline is issued.

The updated guidelines for breast cancer screening for women at average risk

Previously, HRSA guidelines recommended that women who have an average risk of developing breast cancer initiate mammography screening no earlier than age 40 and no later than age 50. Guidelines also recommended that screening mammography should occur at least biennially and as frequently as annually and continue through at least age 74.

HRSA updated its guidelines for breast cancer screening for women at average risk to include additional imaging requirements as part of the screening process. Specifically, health plans and insurers must cover the initial mammography plus any additional imaging, such as magnetic resonance imaging (MRI), ultrasound and mammography, as well as pathology evaluation required to complete the screening process for malignancies.

The breast imaging guidelines are consistent with other preventive care guidance, such as that for colon cancer screening, that essentially requires that the screening be a robust screening including follow-up on any issues that arise in the initial scan, not simply one routine test or exam.

New guidelines for breast and cervical cancer screening services

New HRSA guidelines will require services to help patients navigate breast and cervical cancer screening and follow-up. These services include, but are not limited to:

• Person-centered assessment and planning
• Healthcare access and health system navigation
• Referrals to appropriate support services (e.g., language translation, transportation, and social services)
• Patient education

These navigation services involve person-to-person contact with the patient. The contact can be in person, virtual or both under a hybrid model.

Implications for plan sponsors

Plan sponsors should contact their plan administrator to ensure that they are able to implement and comply with the latest additional requirements for breast imaging and pathology.