The Health Resources and Services Administration Adds to List of Preventive Health Services to be Covered without Cost-Sharing
Employee Benefits
The Health Resources and Services Administration Adds to List of Preventive Health Services to be Covered without Cost-Sharing
On December 20, 2024, the Health Resources and Services Administration (HRSA) approved new Women’s Preventive Services Guidelines. These services include screening and counseling for intimate partner and domestic violence, as well as screening and services related to breast and cervical cancer. Applicable non-grandfathered group health plans must cover these additional services without cost-sharing to the participant for plan years beginning on or after December 20, 2025. More information related to this guidance is contained below.
Background
For group health plans with plan years beginning on or after September 23, 2010, the Affordable Care Act (“ACA”) requires fully insured and self-funded, non-grandfathered group health plans (excluding plans that qualify as HIPAA-excepted benefits) to provide coverage for certain categories of preventive care services without any cost-sharing.
Four categories of preventive care services must be provided without any cost-sharing:
- U.S. Preventive Services Task Force (USPSTF) recommended preventive services that are rated A or B.
- The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) recommended immunizations.
- Additional preventive care and screenings for women not recommended by the USPSTF but provided for in the Health Resources and Services Administration’s (HRSA) guidelines.
- Preventive screenings and care for infants, children and adolescents that are provided for in the HSRA guidelines.
HRSA Updates to the List of Preventive Health Services
HRSA updated its guidance to include additional preventive services for women, effective one year after the issuance of this updated guidance (i.e., December 20, 2025). Practically, for most applicable group health plans, the following services should be covered without cost-sharing for plan years beginning on or after January 1, 2026:
Screening and Counseling for Intimate Partner and Domestic Violence
Annual and as-needed screening for adolescent and adult women for intimate partner and domestic violence, as well as intervention services including counseling, education, harm reduction strategies and appropriate support services.
Intimate partner and domestic violence include physical and sexual violence, stalking and psychological aggression, reproductive coercion, neglect and the threat of violence and/or abuse.
Breast Cancer Screening for Women of Average Risk
Biennial (and as frequent as annual) mammograms for women at average risk of breast cancer starting no earlier than age 40 (and no later than age 50), and this screening should continue until at least age 74. Additional screenings (e.g., MRI, ultrasound or mammogram) may be necessary to complete the screening process or address findings, including malignancies.
Patient Navigation Services for Breast and Cervical Cancer Screening
Individualized person-to-person (i.e., in-person, virtual or hybrid) patient navigation services for breast and cervical cancer screening and follow-up, including person-centered assessment and planning, health care access and health system navigation, referrals to support services (e.g., language translation, transportation and social services) and patient education.
Note: There is ongoing litigation related to the authority of the agencies mentioned above to mandate that plans cover services at no cost sharing to participants. The primary case of Braidwood v. U.S. Department of Health and Human Services only affected the recommendations of the USPSTF (not the HRSA), and the current status of that case only affects the plaintiffs that filed the original lawsuit. Therefore, plan sponsors should continue to comply with the ACA preventive services coverage mandates under the four categories listed above until future guidance is provided. Plan sponsors should also follow developments in this area to ensure continued compliance with these requirements.
Action Plan
Plan sponsors should review their plans with their carrier or third-party administrator (TPA) to confirm coverage of the new preventive care services discussed above as recommended by the HRSA will be provided for the 2026 and subsequent plan years (unless the plan is exempt). As necessary, plan sponsors should update plan documents, summary plan descriptions (SPDs) and summaries of benefits and coverage (SBCs) to reflect these coverage changes.
