Updated Preventive Services Guidelines Expands Coverage Required Without Cost-Sharing

June 12, 2025   •   by Diane Cross   in  Compliance

Tags:

• Coverage without Cost-Sharing
• Preventative Services

Recent guidance from the Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), and the United State Preventive Services Task Force (USPSTF) will impact coverage for women that must be provided by group health plans at no-cost, explained further below.

Background

Non-grandfathered group health plans and insurers are required to cover certain preventive services without cost sharing as provided by HRSA, USPSTF, and the CDC’s Advisory Committee on Immunization Practices (ACIP). Such agencies periodically update their guidelines, requiring plans to cover newly recommended services generally effective for plan years beginning one year after guidance is issued.

Recent Guidance

The new HRSA guidelines require the following preventive services to be covered without cost-sharing for plan years beginning on or after December 20, 2025:

• Screening and Counseling for Intimate Partner and Domestic Violence . Annual adolescent and adult women screening for intimate partner and domestic violence and providing or referring to intervention services (e.g., counseling, education, and harm reduction strategies), as needed.
• Breast Cancer Screening for Women of Average Risk . Initiate mammography screening no earlier than age 40 and no later than age 50, with frequency at least biennially but as frequently as annually, lasting through at least age 74. If additional imaging (e.g., MRI, ultrasound, mammography) and evaluation are indicated, such services are recommended to complete the screening process.  Note this is consistent with current USPSTF guidance, which recommends no-cost biennial screening mammography beginning at age 40.
• Patient Navigation Services for Breast and Cervical Cancer Screening . Individualized patient navigation services for breast and cervical cancer screening based on patient’s need including (not exhaustive) person-centered assessment and planning, health care access and health systems navigation, referrals to appropriate support services (e.g., language translation, transportation, and social services), and patient education.

In addition to the new HRSA guidelines, the USPSTF has issued a final recommendation requiring no-cost coverage of osteoporosis screening using DXA BMD, with or without fracture risk assessment, as well as other bone measurement testing, for plan years beginning on or after February 1, 2026. Currently, group health plans must cover osteoporosis screening at no cost for women aged 65 and older, and for postmenopausal women under 65 who are at increased risk of fracture.

Employer Takeaways

Employers should stay informed about these developments and, for now, ensure their group health plan coverage aligns with:

• HRSA guidance for plan years beginning on or after December 20, 2025 —including decisions on whether to cover mammography screenings annually or biennially, and an evaluation of the cost impact of covering additional imaging and pathology services at 100%; and
• USPSTF’s final recommendation on osteoporosis screening coverage for plan years beginning on or after February 1, 2026 .

Of note, there is current litigation (Kennedy v. Braidwood Management, Inc.) regarding the Affordable Care Act’s requirement for group health plans to cover preventive services without cost-sharing, which could ultimately impact coverage requirements depending on the outcome. Sequoia will continue to monitor this case and communicate updates, as applicable.

Additional Resources

• HRSA: Update to the Health Resources and Services Administration-Supported Women’s Preventive Services Guidelines
• HRSA: Women’s Preventive Services Guidelines
• USPSTF Final Recommendation Statement
• Sequoia Foreword: New Guidance and Reminders on Certain Services Covered Without Cost Sharing

Connect with a Sequoia consultant to learn how Sequoia’s compliance services are integrated in our benefits services and tailored solutions. And if you’re already a Sequoia client, stay on top of your employer obligations with your Compliance Checklist that highlights important compliance dates, action items, and resources.

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