New 2026 ACA Guidelines: Breast Cancer Screenings & Navigation Coverage

Employers should prepare now for significant changes to group health plan requirements starting in 2026. Updated HRSA Women’s Preventive Services Guidelines will expand the scope of breast cancer screening benefits and add new navigation services that must be provided at no cost to plan participants.

What’s Changing in 2026

​Expanded Breast Cancer Screening Coverage

Currently, ACA rules require non-grandfathered health plans to cover routine mammograms for women starting at age 40 with no cost-sharing. Beginning in 2026, coverage must also include:

• Additional imaging (such as ultrasounds and MRIs) when medically indicated (for example, dense breast tissue)
• Pathology services needed to complete screening or evaluate findings

These services must be covered at first-dollar coverage—meaning no copay, deductible, or coinsurance for members when provided in-network.

New Patient Navigation Requirement

Plans will also need to cover patient navigation services for breast and cervical cancer screening and follow-up. Navigation services must be individualized and can be delivered in-person, virtually, or as a hybrid. They include:
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• Care planning and system navigation
• Referrals to supportive resources (e.g., translation, transportation, social services)
• Patient education and coaching

HRSA notes that navigation improves screening rates, leads to earlier detection, and improves treatment outcomes.

Why It Matters

​For Employees & Members

• Greater access to care: Additional imaging and pathology are often key for women with dense breast tissue or elevated risk.
• Fewer financial barriers: No-cost sharing helps reduce disparities in access and supports early detection.
• Potential downsides: Expanded imaging may also lead to increased false positives or unnecessary procedures.

For Employers & Plans
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• Claims administration: Many plans today classify follow-up imaging as diagnostic, requiring cost-sharing. In 2026, employers must ensure claims are processed as preventive when indicated, which may require coding and system updates.
• Increased costs: Covering MRIs, ultrasounds, and navigation services is expected to raise short-term claims costs and may affect premiums.
• Potential savings: Early detection may offset costs over time by reducing intensive treatment needs and minimizing absenteeism.

Action Items for Employers

1. Assess current coverage
   Compare your 2025 benefits to what’s required in 2026, especially for HDHPs that may not yet cover follow-up imaging pre-deductible.
   
   
2. Review claims and coding systems
   Work with carriers and TPAs now to avoid disruptions and member confusion when preventive claims are processed.
   
   
3. Budget for increased costs
   Anticipate higher short-term claims and discuss potential premium impacts with your carriers.
   
   
4. Update plan documents
   Revise SPDs, SBCs, and other member materials to reflect expanded coverage and new navigation benefits.
   
   
5. Communicate changes to employees​
   Consider proactive messaging about expanded coverage and the availability of navigation services.

Key Takeaway: Beginning in 2026, group health plans must cover expanded breast cancer screening (including follow-up imaging and pathology) and provide individualized cancer navigation services—all without cost-sharing. Employers should start preparing now to manage compliance, update claims systems, and budget for the changes.
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