Despite recent uncertainty surrounding the preventive care guideline process, group health plans must continue to provide no-cost coverage of preventive care services in 2026 and subsequent years.
The Affordable Care Act (ACA) requires non-grandfathered group health plans to cover specific preventive health services without cost-sharing (e.g., copayments, deductibles, or other out-of-pocket costs), pursuant to recommendations from three key agencies: The U.S. Preventive Services Task Force (USPSTF); the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention; and the Health Resources and Services Administration (HRSA).
Updates to these recommendations generally take effect beginning with the plan year that starts one year or later after a new recommendation is issued. The following table outlines the new or modified preventive care services that must be covered without cost-sharing beginning January 1, 2026, for calendar year plans.1
| NEW REQUIREMENTS FOR 2026 | |
| Patient Navigation Services for Breast and Cervical Cancer Screening | Patient navigation services for breast and cervical cancer screening and follow-up must now be covered as preventive care to help patients overcome barriers to completing recommended screenings and follow-up care. These individualized services include, but are not limited to, person-centered assessment and planning, help with accessing and navigating the health care system, referrals to appropriate support services (e.g., language translation, transportation, and social services), and patient education. |
| MODIFIED / EXPANDED REQUIREMENTS FOR 2026 | |
| Breast Cancer Screening for Women at Average Risk[1] – Additional Imaging and Services | If additional imaging (e.g., MRI, ultrasound, mammography) and pathology evaluation are indicated to complete the breast cancer screening process or to address findings on the initial screening mammography, such services are required to be covered as preventive care services to complete the screening process for malignancies. |
| Respiratory Syncytial Virus (RSV) Vaccine | The recommendation was modified to apply to adults aged 60 to 74 who are at increased risk and to all adults aged 75 and older. |
| Pneumococcal Vaccine | The recommendation was modified to apply to adults aged 50 and older, and adults aged 19 to 49 who are at increased risk. |
| Influenza Vaccine | The recommendation was expanded to address certain solid organ transplant recipients. |
Employer and Plan Sponsor Next Steps
Employers and plan sponsors should confirm that their third-party administrators are prepared to cover these services as preventive care when necessary, and should review plan and summary plan description language with their counsel to determine whether any amendments are necessary.
This blog was drafted by Natalie M. Miller and Mary Mason, attorneys in the Spencer Fane Overland Park, Kansas, office and Alexandra Reveron, a benefits analyst. For more information, visit www.spencerfane.com.
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1Non-calendar year plans must cover preventive care services for recommendations that were issued at least one year prior to the first day of the plan’s 2026 plan year.
2 HRSA’s existing recommendation (which requires coverage of mammography screening beginning no earlier than age 40 and no later than age 50, and continuing through at least age 74, at least biennially and as frequently as annually) will continue to dictate preventive care coverage despite the USPSTF’s updated recommendation for biennial (every two years) mammography screening for women aged 40-74.
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