Is our employer-provided group health plan required (or merely allowed) to cover additional breast cancer screenings and pathology evaluations after an initial preventive care screening mammogram with no out-of-pocket costs? If required under the Affordable Care Act (ACA), would this affect a high-deductible health plan (HDHP) participant’s ability to contribute to a health savings account (HSA)? Are there any other new ACA preventive care coverage requirements for 2026 plan years?
Yes. Starting in 2026, employer-provided group health plans, including HDHPs, must cover additional breast cancer screenings (e.g., another mammogram, an MRI or an ultrasound) and pathology evaluations after an initial ACA preventive care screening mammogram if the results indicate that further imaging is needed or to complete the screening process. The services must be covered without cost sharing — meaning no copays, coinsurance or deductibles — if the care is received from an in-network provider. Because the ACA requires that a group health plan provide these services, this does not affect an HDHP participant’s ability to contribute to an HSA. Two other changes were made to the ACA preventive care requirements for 2026 plan years and are discussed below.
Under the ACA, non-grandfathered group health plans (whether fully insured or self-insured) must cover certain in-network preventive services without cost sharing. These include those provided by the Health Resources and Services Administration (HRSA), which relies on the Women’s Preventive Services Initiative (WPSI) to develop, review and update the recommendations in response to the unique health needs of women.
On December 20, 2024, HRSA approved updates to the current Women's Preventive Services Guidelines for Breast Cancer Screening for Women at Average Risk as well as Screening and Counseling for Intimate Partner and Domestic Violence. The guidelines also add a requirement regarding Patient Navigation Services for Breast and Cervical Cancer Screening.
These updated guidelines are effective for plan years beginning on or after December 20, 2025 (e.g., January 1, 2026, for calendar-year plans).
Often an initial screening mammogram can be inconclusive or show an irregularity, especially for women with dense breasts. This may require follow-up imaging or pathology evaluations to effectively screen for malignancies, which can be costly to the patient if not covered.
The update to the existing Guideline on Breast Cancer Screening for Women at Average Risk adds new language: “Women may require additional imaging to complete the screening process or to address findings on the initial screening mammography. If additional imaging (e.g., magnetic resonance imaging (MRI), ultrasound, mammography) and pathology evaluation are indicated, these services also are recommended to complete the screening process for malignancies.”
The guidelines also include a new recommendation requiring non-grandfathered group health plans to provide, without cost-sharing, individualized patient “navigation services” provided by in-network providers for breast and cervical cancer screening and follow-up. Patient navigation services involve person-to-person contact with the patient, whether in-person, virtual or both. Services include:
The existing screening recommendation for “interpersonal and domestic violence” for “adolescents and women” has been updated to change the terminology to “intimate partner and domestic violence” for “adolescent and adult women.” The remainder of the recommendation remains unchanged. This screening must be provided with no cost sharing when provided by in-network providers.
Under the Internal Revenue Code, an individual must be covered by an HDHP and have no disqualifying health coverage in order to contribute to an HSA. To qualify as an HDHP, a group health plan may not pay for or reimburse a participant for healthcare expenses incurred before the minimum annual deductible is met ($1,700 for self-only and $3,400 for family in 2026). However, an HDHP is not required to have a deductible for “preventive care,” as defined by the IRS for HSA purposes.
In Notice 2013-57, the IRS interpreted the definition of preventive care to include any preventive health services within the meaning of the ACA mandate, meaning these services can be provided at no cost or with a deductible below the minimum annual HDHP deductible without risking HSA eligibility. Thus, because group health plans are required to provide the preventive services recommended in the updated guidelines, the services will also be considered preventive care for HDHP/HSA purposes.
In addition, in November 2024, the IRS issued Notice 2024-75 clarifying that an HDHP can cover breast MRIs, ultrasounds and similar breast cancer screening services for individuals who have not been diagnosed with breast cancer as preventive care with or without cost-sharing prior to the HDHP minimum annual deductible being satisfied, without putting participants’ ability to contribute to an HSA at risk. Non-grandfathered HDHPs will need to comply with the ACA preventive services mandate, including the updated guidelines, but HDHPs may provide first dollar coverage for all breast cancer screenings, beyond what the ACA requires, without affecting HSA eligibility.[1]
