Plan ahead for expanded breast cancer screening coverage 

Employers need to prepare now for expanded breast cancer screening and navigation coverage requirements applicable to group health plans in 2026.

Updated Health Resources and Services Administration guidelines for women recommend no-cost sharing coverage of imaging in addition to mammograms and pathology when indicated, as well as special navigation services.

The expanded requirements have implications for plan members, claims administration and plan costs.

Breast cancer screening is a preventive service requirement

Under the Affordable Care Act, non-grandfathered insured and self-funded group health plans must provide preventive services in-network without participant cost sharing, meaning without deductibles, copayments or coinsurance – sometimes called “first-dollar coverage.”

Required preventive services include HRSA-supported Women’s Preventive Services Guidelines and recommendations made by the US Preventive Services Task Force and the Advisory Committee on Immunization Practices. Both HRSA and USPSTF make recommendations regarding breast cancer screening.

Breast cancer screening coverage requirement

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

In December 2024, HRSA approved an update that requires plans to cover not only the initial breast cancer screening but also any additional imaging or pathology required to complete the screening process for malignancies or to address findings on the initial screening mammography.

USPSTF also addresses breast cancer and recommends that biennial screening mammography begin at age 40. HRSA’s charge differs from USPSTF in that HRSA’s authority includes additional preventive services and screenings not described in the USPSTF A or B recommendations.

The US Supreme Court recently heard arguments in a challenge to USPSTF’s authority to make preventive services recommendations. The authority of HRSA and ACIP is not currently in question. Because HRSA’s authority to make recommendations is not at issue, its breast cancer screening recommendation – and as a result, group health plan no-cost sharing coverage requirements – will not be impacted by the Supreme Court’s decision.

New cancer navigation services requirement

In addition to the expanded breast cancer screening coverage requirement, in 2026 plans must provide patient navigation services for breast and cervical cancer screening and follow up. According to HRSA, patient navigation services improve screening rates and can lead to better outcomes with earlier cancer identification and treatment.

Specifically, HRSA guidelines call for individualized person-to-person patient navigation in-person, virtually or with a hybrid model. This includes person-centered assessment and planning, healthcare access and health system navigation, referrals to appropriate support services (for example, language translation, transportation and social services) and patient education.

Plan member implications

Both ultrasounds and MRIs have their place in breast cancer screening, particularly for women at higher risk or with dense breast tissue, where the clinician requires an enhanced view to differentiate normal from abnormal findings. The decision to undergo additional imaging or tissue biopsy depends on individual risk factors, breast density and the specific clinical scenario. Patients should discuss their options with their healthcare provider to determine the appropriate approach.

Additional potential implications for plan members include:

• Pros and cons of supplemental screening: Offering breast imaging without participant cost sharing when clinically indicated can significantly enhance access to essential health services and improve early detection rates, which is often associated with better treatment outcomes and survival rates, leading to lower costs overall. In addition, no-cost sharing breast imaging reduces disparities in healthcare access among different socioeconomic groups, promoting health equity. Providing coverage for no-cost sharing ultrasounds and MRIs may also present some risks including false positives, overuse of services and variable quality with increased demand.
• Claims administration challenges: Today, many ERISA-covered plans cover additional imaging of the breast as diagnostic and require members to pay their deductible and co-insurance for these procedures. Employer plan sponsors who cover these services as preventive should work with their carriers to understand any potential coding-related issues to avoid member noise and disruption. Notably, last October, the tri-agencies specifically addressed a plan’s obligation to review coding guidelines, claims processing systems and other relevant internal protocols and to make any necessary modifications to ensure that claims for recommended preventive items or services are covered without cost sharing.

Plan cost implications

As group health plans prepare for the expanded breast cancer screening coverage requirements effective in 2026, assessing the potential cost implications is essential.

The introduction of no-cost sharing for additional imaging, pathology services and patient navigation will have several financial impacts for employers and plan sponsors:

• Increased claims costs: Not surprisingly, expanded coverage for additional imaging like MRIs and ultrasounds and pathology evaluations will likely increase claims costs in the near term. Employers should analyze historical claims data to estimate potential increases in utilization and associated costs.
• Budgeting for navigation services: Individualized patient navigation services will add to overall plan costs. While these services can improve health outcomes and reduce long-term costs through early detection, they require upfront investment.
• Impact on premiums: Increased claims costs may lead to higher insured premiums. Employers should engage with insurance carriers to understand how these changes will affect rates.
• Potential for cost offsets: Initial cost increases may be offset by early detection leading to less aggressive treatments and improved outcomes. Employers should work with actuaries to model these offsets and assess the long-term financial impact.
• Monitoring and evaluation: Close monitoring of utilization patterns and claims data is crucial. Regular evaluations will help identify trends and assess the effectiveness of navigation services.
• Impact on absenteeism: Early detection and treatment of breast cancer can lead to shorter recovery times and reduced absenteeism. By facilitating timely screenings and interventions, employers may see improved employee attendance and productivity, which can offset some of the costs associated with expanded coverage.

Employer next steps

Some employer plans, including HSA-qualified HDHPs, may already be covering breast cancer screening beyond mammograms as preventive care, free of cost-sharing.

Last fall, Notice 2024-75 clarified that HSA-qualifying HDHPs could—but weren’t required to—offer pre-deductible coverage of all types of breast cancer screenings, extending beyond just mammograms.

Employers that chose not to expand pre-deductible coverage to additional types of breast cancer imaging in the 2025 plan will have to in the 2026 plan.

Additional employer considerations include:

• Current coverage: Evaluate current coverage as compared to coverage required for plans beginning in 2026 and determine cost implications, if any.
• Coding guidelines: Review coding guidelines and claim processing systems, especially for plans currently covering additional breast imaging and pathology as diagnostic (with participant cost-sharing). Work in advance with carriers and third-party administrators to identify and remedy potential claim coding complications. Consider implementing member advocacy services to tackle claims processing challenges.
• Communications: Review member-facing plan documents, such as summary plan descriptions (SPDs) and summary of benefits and coverages (SBCs) for any necessary revisions to benefit coverages. Consider member communications announcing new navigation services.