For many women, initial screening mammograms can be a stressful time as they anxiously await the results. As a mammogram is a cancer screening tool, inconclusive outcomes or those that show an irregularity requiring follow-up evaluations can be costly to the patient if not covered. Changes are coming soon on how breast cancer screening is covered by group health plans, a welcoming sign for many women.

Under the Affordable Care Act (ACA), fully insured and self-funded non-grandfathered group health plans must cover certain in-network preventive services without patient cost sharing (e.g., deductibles, copays or coinsurance).

The certain preventative services that must be covered include those recommended by the Health Resources and Services Administration’s (HRSA) Preventive Services Guidelines, services given an “A” or “B” rating from the U.S. Preventive Services Task Force (USPSTF), immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) on breast cancer screening, and other preventive care and screenings in HRSA-supported guidelines for women.

On December 20, 2024, HRSA approved updates to the current Women’s Preventive Services Guidelines for breast cancer screening for women at average risk and also approved a new guideline regarding patient navigation services for breast and cervical cancer screening.

Employers should prepare now for expanded breast cancer screening and navigation coverage requirements applicable to group health plans in 2026, as the new requirements impact plan participants, administration and costs.

Current Guidance

The current HRSA recommendation for breast cancer screening requires group health plans to cover, without participant cost sharing, mammograms for average-risk women—at least every other year and as frequently as annually—beginning “no earlier than age 40 and no later than age 50.” USPSTF recommends screening mammograms every other year for breast cancer beginning at age 40.

When there are changes to recommendations and guidelines, health plans must generally provide coverage reflecting the changes for plan years that begin one year after the change (i.e., a change recommended in December 2024 would take effect in plan years beginning in 2026).

New Guidance

According to the updated HRSA guidelines, employer-sponsored group health plans, including high-deductible health plans (HDHPs), must cover additional breast cancer screenings and pathology evaluations, including additional mammograms, MRIs, ultrasounds and biopsies, if the results of an initial preventive care screening mammogram indicate that further imaging is needed or to complete the screening process.

The additional services must be covered without cost sharing if the services are provided by an in-network provider. Because ACA requires that a group health plan provide these services, this does not affect a HDHP participant’s ability to contribute to a health savings account.

The updated guidelines are effective for plan years beginning on or after December 20, 2025 (e.g., January 1, 2026, for calendar-year plans).

Navigation Services

In addition to the expanded breast cancer screening coverage requirement, in 2026, plans must also provide individualized patient navigation services by in-network providers for breast and cervical cancer screening and follow-up. According to HRSA, patient navigation services improve screening rates and can lead to better results with earlier cancer detection and treatment.

Patient navigation services involve individualized person-to-person contact with the patient (e.g., in-person, virtual or hybrid models). Services 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)
• Patient education.

Plan Participant Implications

According to Mercer, the updated guidelines may affect group health plan participants in the following ways:

• Increased access to essential health services and early detection rates. Offering additional imaging and pathology can lead to better patient outcomes.
• Reduction in health care disparities among diverse groups. Additional imaging without cost sharing promotes health equity for plan participants.
• Overuse of services and false positives. Patients may undergo additional, unnecessary tests when ultrasounds, MRIs and biopsies are not subject to cost sharing, creating anxiety and wasting the patient’s time.
• Lower costs for needed tests. Participants will no longer be required to pay deductibles and co-insurance for additional breast cancer screening, as the additional imaging will no longer be covered as diagnostic.

Group Health Plan Implications

Group health plans should assess and understand cost implications that come with the new breast cancer screening requirements for 2026, as the requirement to provide additional screening and navigation services without cost sharing will impact plan sponsors financially. Impacts, according to Mercer, include:

• Higher claims costs. Employers should analyze claims data to estimate potential increases in utilization and related costs.
• Increased premiums. When claims costs increase, premiums may increase. Employers should discuss this with their insurers to understand how these changes will affect rates.
• Cost offsets. Initial cost increases may be offset by early detection, so employers should work with service providers to assess financial impacts.
• Planning for navigation services’ costs. While long-term costs may be lower, there will be an initial cost to providing personalized services.

Takeaways and Next Steps for Employers

As employers prepare for expanded breast cancer screening and navigation service requirements applicable to group health plans, they must remain aware of cost and administration issues. Employers should:

• Make sure all health plans cover ACA preventive services in-network without cost sharing starting January 1, 2026 for calendar-year plans
• Determine cost differences between current coverage and coverage for the 2026 plan year
• Communicate with employees regarding the new guidance, including updating summary plan descriptions and summary of benefits and coverage documents where necessary
• Consult with service providers regarding necessary updates to plan systems.

Developed by International Foundation Information Center staff. This does not constitute legal advice. Please consult your plan professionals for legal advice.