Insurance Coverage Updates: Federal, State, Individual Insurers
Federal Guideline for Insurance Coverage
Effective Jan 1, 2026, Affordable Care Act compliant plans are now required to cover, for women at average risk, “additional” breast imaging in the Health Resources Services Administration (HRSA)-supported Women’s Preventive Services Initiative (WPSI) recommendations. The new guidelines state, “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 are also recommended to complete the screening process for malignancies.”
More details:
- “While there are currently no randomized controlled trials to support separate recommendations for women with dense breasts, the updated clinical recommendation supports additional testing to complete initial screening, if needed, which may be more common for women with dense breasts.”
- “Non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage must cover without cost-sharing the services and screenings listed on the updated Women’s Preventive Services Guidelines.” For most plans, this update will take effect in 2026.
Our input:
- Federal plans such as Medicare, VHA, and TRICARE and grandfathered plans appear to be exempt. Furthermore, while these updates focus on women at ‘average’ risk, they do not address the supplemental imaging requirements for those at increased or high risk. In contrast, the federal Find It Early Act addresses both of these gaps; we remain committed to advancing that legislation.
- Since federal guidelines are frequently codified through state-level legislation, we anticipate a continued influx of state insurance bills designed to mirror or expand on these federal requirements.
State Insurance Bills
New legislation for insurance coverage of expanded breast imaging:
Arizona SB1165
California AB1570
Florida SB1494
Rhode Island S2032
South Carolina S0820
Insurer Breast Imaging Expansion
Blue Cross Blue Shield affiliated organization Highmark Inc. has announced plan members across 4 states will receive 100% coverage for diagnostic breast studies and MRIs. More HERE.