Effective for plan years beginning after Dec. 30, 2025, group health plans and health insurance issuers must expand their first-dollar coverage for preventive care for women to include additional breast cancer imaging or testing that may be required to complete the initial mammography screening process.
In addition, health plans and issuers must cover patient navigation services for breast and cervical cancer screening without cost sharing.
New Guidelines
The current HRSA-supported guidelines require health plans and issuers to cover, without cost sharing, mammography screening for women at average risk for breast cancer at least biannually and as frequently as annually, beginning no earlier than age 40 and no later than age 50. On Dec. 30, 2024, HRSA updated its breast cancer screening guidelines to include additional imaging to complete the screening process.
Beginning in 2026, most health plans and issuers must cover, without cost sharing, the initial mammography plus any additional imaging (e.g., MRI, ultrasound or mammography) or pathology evaluation required to complete the screening process for malignancies.
In addition, beginning in 2026, most health plans and issuers must provide individualized patient navigation services for breast and cervical cancer screening and follow-up. These services must 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) and patient education.
As always, please do not hesitate to reach out to your Marshall+Sterling Account Manager for more information on how this could impact your plan.
Please note: This Legal Update is not intended to be exhaustive, nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.
