Washington D.C. — Group health plans across the United States must prepare for significant changes in how they cover breast cancer screening and related services. Effective in 2026, federal requirements will expand mandatory coverage to include services beyond routine mammography, all at no cost sharing to plan members.
These impending changes stem from updated guidelines issued by the Health Resources and Services Administration (HRSA) specifically for women. The HRSA guidelines, which were officially approved in December 2024, significantly broaden the scope of preventive care plans must fully cover.
The Mandate Explained
Under the revised HRSA guidelines, group health plans will be required to provide no-cost sharing coverage for a range of services integral to comprehensive breast cancer screening. This includes additional imaging beyond standard mammograms, such as Magnetic Resonance Imaging (MRIs) and ultrasounds, when clinically indicated. Furthermore, the mandate extends to pathology services when required as part of the screening process or follow-up.
A crucial addition to the required no-cost coverage is the inclusion of special navigation services. These services are designed to help individuals navigate the often complex process of screening, follow-up appointments, and potential diagnosis.
Previously, HRSA recommendations focused on requiring no-cost sharing for mammography performed biennially to annually for average-risk women aged 40 and older, typically extending beyond age 50.
Expanding the Scope of Care
The expansion necessitates coverage not just for the initial screening but for any follow-up imaging or pathology that is required to complete the screening process or address initial findings. This means if a mammogram reveals an area requiring further investigation, the subsequent imaging (MRI or ultrasound) and any necessary biopsy or pathology to evaluate findings must also be covered without co-pays, deductibles, or co-insurance.
The goal is to ensure that cost barriers do not prevent individuals from completing necessary follow-up care triggered by a screening result, thereby improving early detection rates and outcomes.
Implications for Stakeholders
The broadened coverage requirements will have multifaceted implications across the healthcare system and for plan stakeholders.
For plan members, this represents a significant step towards improved access to comprehensive breast cancer screening and diagnostic follow-up. The elimination of cost sharing for these services removes a potential financial barrier that could deter individuals from pursuing necessary tests.
However, for plan administrators and sponsors, the changes will necessitate adjustments. Claims administration processes will need to be updated to correctly identify and process these expanded services under the no-cost sharing mandate. This will require careful attention to coding and billing to ensure compliance.
Moreover, the most direct financial impact will be felt by employers and plan sponsors. The requirement to cover additional imaging, pathology, and navigation services without cost sharing will inevitably lead to increased claims costs for group health plans.
Implications for HDHPs
A specific clarification regarding High Deductible Health Plans (HDHPs) that are HSA-qualified was provided in Notice 2024-75. This notice addressed the coverage of breast cancer screenings before the deductible is met.
Notice 2024-75 clarified that while pre-deductible coverage for all types of breast cancer screenings (including those now mandated) was optional for HSA-qualified HDHPs in plans for the 2025 plan year, it will become required starting with plans effective in 2026.
This means that for 2026 and subsequent years, HSA-qualified HDHPs must cover the full spectrum of mandated breast cancer screening and follow-up services at no cost to the member, even if the member has not yet met their annual deductible.
Preparing for Change
With the 2026 effective date approaching, U.S. group health plans have a window to prepare for these significant changes. This includes reviewing current benefit designs, updating plan documents and member communications, educating claims processing teams, and forecasting potential increases in healthcare expenditures related to these expanded benefits.
This information comes from analysis conducted by Mercer, a business of Marsh McLennan, highlighting the need for proactive planning by health plan administrators and sponsors to ensure compliance and manage the financial impact of these new federal mandates aimed at enhancing breast cancer screening accessibility for women.
