Beginning with plan years starting after December 30, 2025, group health plans and health insurance issuers will be required to expand their preventive care coverage for breast cancer screening under the Affordable Care Act (ACA). These updates are part of a growing national emphasis on early detection and comprehensive patient support—both vital components of improving health outcomes for women.
In our previous blog post on preventative care, we discussed how first-dollar coverage of screenings and immunizations helps employers support healthier, more engaged workforces. Now, with the latest update from the Health Resources and Services Administration (HRSA), plan sponsors must prepare for even more robust requirements aimed at closing gaps in early cancer detection and care.
First-dollar coverage means that the health plan pays for eligible services from the very first dollar, without deductibles, copayments, or coinsurance. This differs from other types of services under most health plans where the insured must first meet an out-of-pocket threshold before benefits apply.
A woman goes in for her routine, annual screening mammogram at an in-network facility. Even though her health insurance plan has a $2,000 deductible, she pays nothing out of pocket for the mammogram because it is considered a preventive service. The plan covers the full cost of the screening from the first dollar, meaning no deductible, copay, or coinsurance applies. Starting in 2026, if additional imaging such as an ultrasound or MRI is needed to complete a screening, those services must also be covered in full.
Under the ACA, non-grandfathered group health plans must cover recommended preventive services without cost sharing when delivered by in-network providers. These include services rated A or B by the U.S. Preventive Services Task Force and guidelines supported by HRSA.
Effective for plan years beginning on or after December 30, 2025, the following changes apply:
Health plans must now cover not only the initial mammogram but also any additional imaging or pathology evaluations needed to complete the screening process. This may include:
This is especially critical when initial screening results are inconclusive or raise concerns, ensuring that individuals can pursue further evaluation without delay or financial burden.
Plans must also cover individualized patient navigation services for breast and cervical cancer screenings, including:
These services are designed to reduce disparities in care and improve health outcomes by supporting patients through complex care systems.
The upcoming changes to breast cancer screening requirements reinforce the importance of first-dollar coverage in preventive care. By eliminating cost barriers for additional imaging and offering patient navigation support, these updates will help close care gaps and lead to earlier diagnoses and better outcomes.
Not sure how these changes impact your current benefits? RMC Group is here to help you build a smarter, more supportive plan—one that puts preventive care and your people first.
Click here to schedule a meeting today with out Health Insurance Team.