The Affordable Care Act (ACA) requires non-grandfathered health plans to cover a specific list of preventive health services in-network without cost-sharing to the plan participant. As ACA-required preventive service recommendations are updated, plan years starting one year after the new recommendation must cover those updated services in-network with no cost-sharing.
The insurance carrier or third-party administrator (TPA) should keep up with these published updates to ensure inclusion in group health plans at the required time. Among the various updates coming for plan years beginning in 2026 are three updates specific to women’s preventive services. One may require an update to employer’s budgets and one requires care navigation services, which the carrier or TPA may not currently provide.
Applies To:
Employers sponsoring non-grandfathered medical plans must ensure ACA-required preventive care services are covered in-network without cost-sharing.
Go Deeper:
In December 2024, the federal agency responsible for women’s preventive service recommendations published three updates which non-grandfathered health plans must adjust to cover in-network without cost-sharing for plan years starting in 2026.
- Updated guidelines for domestic violence screening to:
- Change the term “interpersonal violence” to “intimate partner violence,” and
- Change the potential need to provide or refer for “initial intervention services” to remove the word “initial” (so plans should be prepared to provide or refer for intervention services even beyond the initial provision or referral).
- Updated guidelines for breast cancer screening for women at average risk ages 40 to 74:
- When the initial mammogram medically indicates a potential issue, the plan will be newly required to cover in-network without cost-sharing (a) extra imaging services such as MRI, ultrasound, or another mammogram, and (b) pathology evaluation to screen for and identify any potential concerns
- “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.”
- A new guideline requiring coverage of “patient navigation services for breast and cervical cancer screening and follow-up, as relevant, to increase utilization of screening recommendations based on an assessment of the patient’s needs for navigation services.”
- “Patient navigation services involve person-to-person (e.g., in-person, virtual, hybrid models) contact with the patient.”
- “Components of patient navigation services should be individualized.”
- “Services include, but are not limited to, 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.”
This is not an exhaustive list of all updates to ACA-required preventive services for 2026, but two of these women’s preventive services may require extra attention from employers.
Penalties for Non-Compliance
Non-grandfathered plans that fail to cover ACA-required preventive care services in-network without cost-sharing may be subject to a penalty of $100 per person per day plus a requirement to pay retroactively for services the plan should have covered.
Practical Impact to Employers:
While the carrier or TPA should keep the plan updated with ACA-required preventive services as they are published, the new requirements to cover additional imaging following an initial mammogram can add enough extra costs to the plan that self-funded employers may want to budget for those in advance. Employers will also want to ensure the carrier or TPA can accommodate the new individualized care navigation services to educate women and help them plan for breast and cervical cancer screenings.
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