Star Rating performance data in the Care Gap Management Application (CGMA) reflects recent changes to cutpoints for our Medicare Advantage quality incentive programs for the 2025 program year. Some cutpoints increased, some decreased and others remain unchanged.

The updated cutpoints ensure alignment with national performance trends monitored by CMS and support improved care quality for the 2025 program year.

View the updated cutpoints in the Medicare Advantage Incentive Programs Rules flyer.

10/31/2025

Effective January 1, 2026, we will expand coverage for preventive breast cancer screening services for our commercial members in alignment with updated federal guidance from the Health Resources and Services Administration (HRSA) and the Women's Preventive Services Initiative (WPSI). These organizations define what can be covered under Affordable Care Act (ACA) preventive care.

What’s changing
Under the new federal guidance, breast cancer screenings will include not only mammograms (currently covered) but also additional imaging and pathology evaluations. These services will be covered as preventive care with no member cost share, regardless of whether the member is enrolled in a health savings account (HSA) or non-HSA plan.

Expanded services include:

• Imaging: MRIs, ultrasounds and contrast mammography
• Pathology: Tissue biopsies and related pathology analysis

This broader coverage applies to members of all risk levels, ensuring that anyone who needs screening—regardless of personal or family history—can access comprehensive services without financial barriers.

Impact on state mandates

The ACA preventive benefit now encompasses requirements already mandated in Washington. While state-specific language may still appear in policy documents, the benefits themselves will be administered under ACA preventive guidelines, which are broader and more inclusive.

Clarification on cancer diagnoses
A key distinction for 2026 is how screenings are handled for members with an active cancer diagnosis:

• These screenings are not considered preventive under ACA or Internal Revenue Services (IRS) guidelines
• Therefore, standard radiology cost shares will apply, even for non-HSA products

For HSA products:

• Deductibles will be waived only for members without an active cancer diagnosis
• Members with an active cancer diagnosis will have deductible applied, consistent with IRS Notice 2024-75

Preventive care flyer updates

Our preventive flyers have been updated to reflect the expanded breast cancer screening coverage.

10/27/2025

We've updated our HIV Pre-Exposure Prophylaxis (PrEP) coverage to ensure all appropriate services are covered with no member copay or coinsurance in alignment with the Affordable Care Act FAQ (Part 68) and U.S. Preventive Services Task Force regulatory guidance.

Claims to be reprocessed

• We will begin reprocessing claims by early November 2025 for qualified services received from August 1, 2024, through October 9, 2025. Members will receive an updated Explanation of Benefits.
• Providers who performed eligible services during this time will need to refund any applicable cost share payments to their patients.
  • If a member used HSA funds to pay their provider, the member may need to deposit those funds back into their HSA to avoid tax implications. (Members can consult their tax advisor or HSA administrator for guidance.)

What's covered on or after August 1, 2024

• PrEP medications and monitoring services
• Required laboratory testing and screenings, such as kidney function and sexually transmitted diseases
• Office visits for PrEP consultation and follow-up

Important coding requirements
Best practice: Use Z29.81 (Encounter for HIV pre-exposure prophylaxis) when possible, as this is the most specific code for PrEP services.

To ensure proper claim processing and prevent appeals, please note these diagnosis code coupling requirements.

For claims using codes non-specific to PrEP therapy, additional diagnosis codes are required:

• Z79.899 (Other long term current drug therapy)
  • For professional claims, Z79.899 must be in the primary position. For facility claims, Z79.899 can be in any position.
  • The claim must include one or more of these additional codes: Z29.81, Z20.6, Z72.51, Z72.52, Z72.53.
• Z51.81 (Encounter for therapeutic drug level monitoring) -
  • For professional claims, Z51.81 must be in the primary position. For facility claims, Z51.81 can be in any position.
  • The claim must include one or more of these additional codes: Z29.81, Z20.6, Z72.51, Z72.52, Z72.53.

10/21/2025