ModifiedUnitedHealthcarePolicy BIP133.Q

Preventive Care Services (federal/state mandated preventive services)

Defines UnitedHealthcare coverage obligations for preventive services required by federal law (PPACA) and certain state regulations, including updated HRSA women's preventive services guidelines; affects network providers and members of non-grandfathered plans (group and individual) where applicable.

Policy Summary

PayerUnitedHealthcare

PolicyPreventive Care Services (federal/state mandated preventive services)

Policy CodePolicy BIP133.Q

Change TypeModified — HRSA guideline updatesCA statutory revisionsbiomarker testing rules

Effective DateJun 1, 2026

Next Review Date

Key ActionCover HRSA-listed women's preventive services without cost-sharing for non-grandfathered group and individual plans beginning in plan/policy years that start one year after the Notice.

SourceLink

POLICY UPDATE CHANGES

HRSA updated Women's Preventive Services Guidelines to include screening and counseling for intimate partner and domestic violence, breast cancer screening for average-risk women, and patient navigation services for breast and cervical cancer screening.

Revised language pertaining to several California Health and Safety Code sections including 1367.3, 1367.35, and 1367.695 and removed language pertaining to CCR Title 10 Section 2594.3.

Legislative amendment (AB 144) updates scope of licensed clinicians permitted to refer under Section 1367.3 and updates pediatric preventive care immunization reference to 2025 schedule.

Biomarker testing coverage requirements and prior authorization limitations established for advanced/metastatic cancer and broader biomarker coverage criteria effective 2024–2024 statutory changes.

A/B USPSTFPreventive services covered without cost-sharing per PPACA

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Coverage Criteria and Scope

Preventive Services Coverage Requirements

Covered preventive services when requirements of PPACA, USPSTF A/B recommendations, HRSA women's preventive services, and applicable state statutes are met:

Federal PPACA Preventive Services: Services with a current USPSTF A or B rating are covered without cost-sharing when delivered by network providers to members of non-grandfathered plans.

Source: PPACA summary

HRSA Women's Preventive Services (updated): Screening and counseling for intimate partner and domestic violence; breast cancer screening for average-risk women starting no earlier than age 40 and no later than age 50 with screening at least biennially and as frequently as annually through at least age 74; and patient navigation services for breast and cervical cancer screening and follow-up — all to be covered without cost-sharing for non-grandfathered group and individual plans beginning in plan/policy years that start 1 year after the Notice.

Source: HRSA Women's Preventive Services Guidelines

State screening requirements (example: CA Hepatitis B/C): California requires offering hepatitis B and C screening in primary care settings per USPSTF indications; if the patient accepts and the test is positive, the provider must offer follow-up care or refer the patient for follow-up (HCV RNA diagnostic testing for HCV positive results); offers must be culturally and linguistically appropriate.

CA HSC §1316.7

Statutory Coverage Criteria

Covered when statutory criteria are met

State-mandated preventive services: Plans must provide coverage for specified preventive services and screenings (for example: pediatric preventive care per AAP recommendations and the 2025 Recommended Childhood Immunization Schedule; breast cancer screening, including coverage for screening, diagnosis and treatment upon referral; annual cervical cancer screening tests including Pap and FDA‑approved HPV tests; and mammography upon referral) when required by the cited Health & Safety Code sections.

References: HSC Sections 1367.35, 1367.6, 1367.64/1367.65, 1367.66

Biomarker testing coverage criteria: Medically necessary biomarker testing shall be covered when it meets at least one of: (1) a labeled indication for an FDA‑approved or cleared test or is an indicated test for an FDA‑approved drug; (2) a CMS national coverage determination; (3) a local coverage determination by a Medicare Administrative Contractor for California; (4) evidence‑based clinical practice guidelines supported by peer‑reviewed literature; or (5) standards set by the National Academy of Medicine.

HSC Section 1367.667

Prior-authorization exemptions for advanced/metastatic cancer: For enrollees with advanced or metastatic stage III or IV cancer, plans shall not require prior authorization for biomarker testing for initial testing or for testing for progression or recurrence; notwithstanding this, plans may require prior authorization for biomarker testing that is not for an FDA‑approved therapy for advanced/metastatic cancer.

Religious employers that meet the criteria set forth in federal regulations may be exempt from the statutory requirement to cover contraceptive services. Specifically, HHS amended the prevention regulation to permit certain religious institutions that offer insurance to their employees to choose whether or not to cover contraception services; group health plans sponsored by those religious employers and related group health insurance coverage are therefore exempt from the contraceptive coverage requirement. Refer to 45 CFR 147.132 and 45 CFR 147.133 for the regulatory provisions governing religious and moral exemptions.

Some Health & Safety Code provisions explicitly exclude specialized health care service plans from specified preventive service mandates. For example, HSC Section 1367.66 requires coverage for cervical cancer screening and FDA‑approved HPV vaccination for enrollees but expressly excepts specialized health care service plans from that mandate. Where a statutory exclusion applies to a plan, carrier-specific plan language and scope determine coverage; for services and scenarios not covered by statute or where plan type excludes the mandate, see the Medical Policy titled Preventive Care Services for UnitedHealthcare's coverage positions and exclusions.

When state-mandated requirements do not apply to a particular plan or benefit (for example, because the plan is a specialized health care service plan or because the statutory trigger is not met), coverage determinations revert to UnitedHealthcare's Medical Policy framework. Consult the Medical Policy titled Preventive Care Services to determine which preventive services are considered not medically necessary or excluded under plan terms and to review applicable referral and utilization review requirements referenced in the statutes (e.g., provider referral requirements cited in HSC Section 1367.66).

Coding, Screening Ages, and Cancer Staging

No explicit CPT/HCPCS/ICD-10 codes in this portionmixed

No codes listed

Covered CPT Codesmixed

No codes listed

Breast cancer screening initiation age window

Initiation age windowWomen at average risk: initiate mammography no earlier than age 40 and no later than age 50.

Screening frequencyScreening mammography should occur at least biennially and may be performed as frequently as annually.

Additional imagingWomen may require additional imaging (e.g., MRI, ultrasound, additional mammography) and pathology evaluation as indicated to complete the screening process.

Duration of screeningScreening should continue through at least age 74 years; age alone should not be the basis for discontinuing screening.

Increased-risk individualsWomen at increased risk should undergo periodic mammography screening; recommendations for additional services are beyond this guideline's scope.

Provider Actions, Prior Authorization, and Referral Requirements

Note

HRSA Women's Preventive Services — Coverage Timing

Non-grandfathered group and individual plans must cover the updated HRSA Women's Preventive Services Guidelines without cost-sharing for plan/policy years beginning one year after the guideline effective date (generally taking effect for Section 2713 coverage in 2026). Providers should ensure these services and screenings are billed and provided without member cost-sharing when applicable.

Applies to non-grandfathered group health plans and individual market policies
Effective for plan/policy years beginning 1 year after the HRSA guideline date (commonly effective for 2026 Section 2713 coverage)
Reference: https://www.hrsa.gov/womensguidelines

Prior Authorization

Biomarker Testing — Prior Authorization Restrictions and Coverage Requirements

Do not require prior authorization for biomarker testing for enrollees with advanced or metastatic (stage III/IV or stage 3/4) cancer when the testing is for diagnosis, treatment, appropriate management, monitoring of disease, to identify actionable alterations for FDA‑approved therapies, or otherwise meets the statutory coverage criteria. Plans must provide biomarker testing in a way that minimizes care disruption (for example, avoid requiring multiple biopsies).

Key Definitions

United States Preventive Services Task Force (USPSTF)

AcronymUSPSTF stands for the United States Preventive Services Task Force.

RoleIndependent panel that issues evidence‑based recommendations (grades A and B referenced for preventive coverage under federal law).

Coverage implicationServices with a current USPSTF A or B rating are covered without cost‑sharing for members of non‑grandfathered plans under the PPACA.

Patient Protection and Affordable Care Act (PPACA)

AcronymPPACA means the Patient Protection and Affordable Care Act of 2010.

Coverage requirementRequires nongrandfathered group and individual health plans to cover evidence‑based preventive services (USPSTF A/B and HRSA women's services) without member cost‑sharing.

Background and Policy Context

Under the Patient Protection and Affordable Care Act, non‑grandfathered group and individual health plans must cover evidence‑based preventive services without member cost‑sharing when those services are supported by the USPSTF (Grade A or B) or listed on the HRSA‑supported Women's Preventive Services Guidelines. HRSA's December 20, 2024 update added screening and counseling for intimate partner and domestic violence, revised breast cancer screening guidance for average‑risk women, and patient navigation services for breast and cervical cancer screening. These HRSA‑listed services must be covered without cost‑sharing for applicable plans beginning in plan/policy years that start one year after the Notice, which generally makes the Section 2713 coverage requirement effective for most plans in 2026.

Revision History and Policy Changes

2026-06-01policy_revisionLatest

Policy revised with updated language related to HRSA/HSC provisions (Legislative Bulletin FD1203 religious exception, HSC Sections 1367.3, 1367.35, and 1367.695) and removal of language referencing CCR Title 10 Section 2594.3; previous policy version BIP133.P archived.

2024-12-20guideline_update

HRSA updated Women's Preventive Services to include intimate partner and domestic violence screening, revised breast cancer screening guidance for average-risk women, and patient navigation services (effective for plan/policy years beginning one year after the Notice).

Policy Summary

PayerUnitedHealthcare

PolicyPreventive Care Services (federal/state mandated preventive services)

Policy CodePolicy BIP133.Q

Change TypeModified — HRSA guideline updatesCA statutory revisionsbiomarker testing rules

Effective DateJun 1, 2026

Next Review Date

Key ActionCover HRSA-listed women's preventive services without cost-sharing for non-grandfathered group and individual plans beginning in plan/policy years that start one year after the Notice.

SourceLink

On This Page

Stage thresholdAdvanced or metastatic cancer defined as Stage III or Stage IV (stage 3 or 4).

Prior-authorization exemptionPlans shall not require prior authorization for biomarker testing for an enrollee with advanced or metastatic stage 3 or 4 cancer, including testing for progression or recurrence.

Scope limitationExemption applies to initial testing and testing for progression/recurrence as specified; plans may still require prior authorization for biomarker testing not tied to FDA‑approved therapy for advanced/metastatic cancer.

Relation to colorectal/other statutesThese stage-based prior-authorization rules are codified alongside other HSC provisions that govern preventive screening coverage and cost‑sharing requirements.

Billing Rule

Cost-sharing Prohibition for USPSTF 'A'/'B' and HRSA Women's Preventive Services

Services and screenings rated 'A' or 'B' by the U.S. Preventive Services Task Force and services in HRSA women's preventive services guidelines must be covered without member cost-sharing for non-grandfathered plans. Providers should confirm coverage and submit claims indicating preventive service status to avoid inappropriate cost-sharing.

Includes USPSTF A or B recommendations and HRSA women's preventive services
Applies only to non-grandfathered group and individual plans
Providers must bill using appropriate preventive service codes and documentation to support no cost-sharing

Denial Risk

Grievance and Appeal Rights for Denied or Restricted Biomarker Testing

Restricted or denied biomarker testing that is needed for diagnosis, treatment, or ongoing monitoring is subject to the plan's grievance and appeal processes and applicable state and federal external review mechanisms. Providers and members should be informed of appeal rights and timelines when testing is denied or limited.

Denials or limitations of biomarker testing are subject to internal grievance and state/federal appeals, including Independent Medical Review when applicable
Document clinical rationale and supporting evidence when appealing denied biomarker testing

Documentation Required

Hepatitis B and C Screening — Offer and Positive Result Actions

When hepatitis B or C screening is offered, follow state requirements: offer screening per USPSTF indications when providing primary care services (unless exceptions apply). If the hepatitis B screening (HBsAg) is positive, the provider must offer follow-up care or refer to a provider who can provide follow-up care. If hepatitis C screening is positive, the provider must offer follow-up care or referral that includes diagnostic HCV RNA testing.

Offer HBV and HCV screening to adult primary care patients per USPSTF unless exception applies (e.g., emergency, prior offering, lack of capacity)
If HBsAg positive: offer follow-up care or referral to a provider who can provide follow-up care
If HCV screening positive: offer follow-up care or referral and include HCV RNA diagnostic testing as part of follow-up

Documentation Required

Provider Operational Obligations: Referrals, Documentation, and Cultural Competence

Additional operational notes for providers: referrals for certain covered screenings (for example, annual cervical cancer screening) may require referral by an authorized participating provider per applicable state law; and ensure culturally and linguistically appropriate offering and documentation for hepatitis screening. Maintain documentation of offers, patient acceptance/declination, referrals, and follow-up arrangements to support compliance and claims.

Cervical cancer screening coverage may require referral from an authorized provider — verify plan requirements and submit appropriate referral documentation
Hepatitis screening offers must be culturally and linguistically appropriate
Document offers, results, referrals, and follow-up plans to support coverage and appeal rights

Intimate partner and domestic violence

DefinitionIntimate partner and domestic violence includes physical violence, sexual violence, stalking, and psychological aggression (including coercion).

Additional formsAlso includes reproductive coercion, neglect, and the threat of violence or abuse.

Screening recommendationRecommend screening adolescent and adult women at least annually and providing or referring to intervention services when needed.

Intervention servicesIntervention services include counseling, education, harm reduction strategies, and appropriate supportive services.

Biomarker testing

DefinitionBiomarker testing means analysis of an individual's tissue, blood, or other biospecimen for the presence of a biomarker.

Test types includedIncludes single‑analyte tests, multiplex panel tests, and whole genome sequencing (and single or multigene diagnostic tests of biospecimens for DNA/RNA alterations or phenotypic characteristics).

Clinical usePerformed to identify cancer subtypes, guide patient treatment, or evaluate progression/recurrence; statutory provisions address coverage and prior‑authorization rules for such testing in advanced/metastatic cancer.

Material changes in this revision include the HRSA update to Women's Preventive Services Guidelines—adding intimate partner and domestic violence screening, revised guidance on breast cancer screening for average‑risk women (initiation between ages 40–50 with at least biennial screening through at least age 74), and explicit inclusion of patient navigation services—applied to non‑grandfathered group and individual plans effective for plan/policy years beginning one year after the Notice (generally effective in 2026). Additionally, the policy reflects statutory revisions to California Health & Safety Code sections and new biomarker testing coverage and prior authorization rules; these state law changes and the policy updates are effective as summarized in the policy's effective date and changes log (see policy effective date 06/01/2026).