No official summary available for this bill.
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5813 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 5813
To amend title XXVII of the Public Health Service Act, the Employee
Retirement Income Security Act of 1974, and the Internal Revenue Code
of 1986 to require group health plans and health insurance issuers
offering group or individual health insurance coverage to provide
coverage of certain items and services relating to breast or chest wall
reconstruction furnished in connection with breast cancer treatment.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
October 24, 2025
Mrs. Cammack (for herself, Mrs. Dingell, Mrs. Hinson, Mrs. McBath, Mrs.
Kim, Mrs. McClain Delaney, Ms. Van Duyne, Ms. Perez, and Ms. Pettersen)
introduced the following bill; which was referred to the Committee on
Energy and Commerce, and in addition to the Committees on Ways and
Means, and Education and Workforce, for a period to be subsequently
determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XXVII of the Public Health Service Act, the Employee
Retirement Income Security Act of 1974, and the Internal Revenue Code
of 1986 to require group health plans and health insurance issuers
offering group or individual health insurance coverage to provide
coverage of certain items and services relating to breast or chest wall
reconstruction furnished in connection with breast cancer treatment.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Women's Health and Cancer Rights
Modernization Act of 2025''.
SEC. 2. REQUIRING COVERAGE OF CERTAIN ITEMS AND SERVICES RELATING TO
BREAST OR CHEST WALL RECONSTRUCTION FURNISHED IN
CONNECTION WITH BREAST CANCER TREATMENT.
(a) PHSA.--
(1) In general.--Part D of title XXVII of the Public Health
Service Act (42 U.S.C. 300gg-111 et seq.) is amended by adding
at the end the following new section:
``SEC. 2799A-11. REQUIRED COVERAGE FOR CERTAIN ITEMS AND SERVICES
RELATING TO BREAST OR CHEST WALL RECONSTRUCTION FURNISHED
IN CONNECTION WITH BREAST CANCER TREATMENT.
``(a) In General.--A group health plan, and a health insurance
issuer offering group or individual health insurance coverage, that
provides medical and surgical benefits with respect to the treatment of
breast cancer shall provide, in the case of a participant or
beneficiary who is receiving such treatment and who elects breast or
chest wall reconstruction in connection with such treatment, coverage
for--
``(1) extirpation or medical treatment of diseased or
damaged breast tissue, including mastectomy and all forms of
breast-conserving surgery;
``(2) each modality of breast reconstruction, including--
``(A) implant-based reconstruction;
``(B) tissue-based reconstruction; and
``(C) any reconstruction modalities that are
developed subsequent to the date of the enactment of
this subsection and recognized within Level I of the
Healthcare Common Procedure Coding System;
``(3) within each modality specified in paragraph (2), each
type of breast reconstruction, including--
``(A) immediate implant-based reconstruction;
``(B) delayed implant-based reconstruction;
``(C) myocutaneous flap tissue-based
reconstruction;
``(D) microvascular free flap tissue-based
reconstruction; structural fat grafting tissue-based
reconstruction;
``(E) combined implant- and tissue-based
reconstruction; and
``(F) any type of reconstruction that is developed
subsequent to the effective date of this act and
incorporated within Level I of the Healthcare Common
Procedure Coding System;
``(4) within each type of breast reconstruction specified
in paragraph (3), each procedural variation, iteration, or
approach that is noted within the short descriptor or the
description for the Healthcare Common Procedure Coding System
Level I code covering the type of reconstruction;
``(5) all stages of reconstruction of the breast or chest
wall on which a mastectomy or breast-conserving surgery has
been performed, including flat closure;
``(6) surgery and reconstruction of the other breast or
chest wall to produce a symmetrical appearance;
``(7) custom fabricated breast prostheses, including
replacement of such prostheses; and
``(8) mechanical, medical, and surgical treatment of
physical complications of mastectomy, breast reconstruction
surgery, chest wall surgery, radiation, and lymph node surgery,
including lymphedema compression treatment items (as such term
is defined in section 1861(mmm) of the Social Security Act but
without regard to the requirement in paragraph (1) of such
section that such an item be furnished on or after January 1,
2024).
``(b) Manner of Coverage.--Coverage described in subsection (a)
shall be provided in a manner determined in consultation with the
attending physician and the patient and for which the patient is a
medical candidate. Such coverage may be subject to annual deductibles
and coinsurance provisions as are consistent with those established for
other benefits under the plan or coverage. Written notice of the
availability of such coverage shall be delivered to the participant
upon enrollment and annually thereafter.
``(c) In-Network Access.--A group health plan and a health
insurance issuer offering group or individual health insurance coverage
shall ensure that at least 1 in-network provider is available under
such plan or coverage with respect to each modality, type of
reconstruction, and procedural variation, iteration, and approach
described in subsection (a).
``(d) Notice.--A group health plan, and a health insurance issuer
offering group or individual health insurance coverage, shall provide
notice to each individual enrolled under such plan regarding the
coverage required by this section in accordance with regulations
promulgated by the Secretary. Such notice shall be in writing and
prominently positioned in any literature or correspondence made
available or distributed by the plan or issuer and shall be
transmitted--
``(1) upon such individual's enrollment in such plan or
coverage; and
``(2) as part of any yearly informational packet sent to
the individual thereafter.
``(e) Prohibitions.--A group health plan, and a health insurance
issuer offering group or individual health insurance coverage, may
not--
``(1) deny to a patient eligibility, or continued
eligibility, to enroll or to renew coverage under the terms of
the plan, solely for the purpose of avoiding the requirements
of this section; and
``(2) penalize or otherwise reduce or limit the
reimbursement of an attending provider, or provide incentives
(monetary or otherwise) to an attending provider, to induce
such provider to provide care to an individual participant or
beneficiary in a manner inconsistent with this section or with
generally accepted standards of medical practice.
``(f) Rule of Construction.--Nothing in this section shall be
construed to prevent a group health plan or a health insurance issuer
offering group or individual health insurance coverage from negotiating
the level and type of reimbursement with a provider for care provided
in accordance with this section.
``(g) Preemption.--Nothing in this section shall be construed to
preempt any State law with respect to health insurance coverage that
requires coverage of at least the coverage of breast cancer care
otherwise required under this section.''.
(2) Conforming amendment.--Section 2727 of the Public
Health Service Act (42 U.S.C. 300gg-27) is amended by adding at
the end the following new sentence: ``The preceding sentence
shall not apply with respect to plan years beginning on or
after the date of the enactment of this sentence.''.
(b) ERISA.--
(1) In general.--Section 713 of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1185b) is amended--
(A) in the header, by striking ``reconstructive
surgery following mastectomies'' and inserting
``certain items and services relating to breast or
chest wall reconstruction furnished in connection with
breast cancer treatment'';
(B) by amending subsection (a) to read as follows:
``(a) In General.--A group health plan, and a health insurance
issuer providing health insurance coverage in connection with a group
health plan, that provides medical and surgical benefits with respect
to the treatment of breast cancer shall provide, in the case of a
participant or beneficiary who is receiving such treatment and who
elects breast or chest wall reconstruction in connection with such
treatment, coverage for--
``(1) extirpation or medical treatment of diseased or
damaged breast tissue, including mastectomy and all forms of
breast-conserving surgery;
``(2) each modality of breast reconstruction, including--
``(A) implant-based reconstruction;
``(B) tissue-based reconstruction; and
``(C) any reconstruction modalities that are
developed subsequent to the date of the enactment of
this subsection and recognized within Level I of the
Healthcare Common Procedure Coding System;
``(3) within each modality specified in paragraph (2), each
type of breast reconstruction, including--
``(A) immediate implant-based reconstruction;
``(B) delayed implant-based reconstruction;
``(C) myocutaneous flap tissue-based
reconstruction;
``(D) microvascular free flap tissue-based
reconstruction; structural fat grafting tissue-based
reconstruction;
``(E) combined implant- and tissue-based
reconstruction; and
``(F) any type of reconstruction that is developed
subsequent to the effective date of this act and
incorporated within Level I of the Healthcare Common
Procedure Coding System;
``(4) within each type of breast reconstruction specified
in paragraph (3), each procedural variation, iteration, or
approach that is noted within the short descriptor or the
description for the Healthcare Common Procedure Coding System
Level I code covering the type of reconstruction;
``(5) all stages of reconstruction of the breast or chest
wall on which a mastectomy or breast-conserving surgery has
been performed, including flat closure;
``(6) surgery and reconstruction of the other breast or
chest wall to produce a symmetrical appearance;
``(7) custom fabricated breast prostheses, including
replacement of such prostheses; and
``(8) mechanical, medical, and surgical treatment of
physical complications of mastectomy, breast reconstruction
surgery, chest wall surgery, radiation, and lymph node surgery,
including lymphedema compression treatment items (as such term
is defined in section 1861(mmm) of the Social Security Act but
without regard to the requirement in paragraph (1) of such
section that such an item be furnished on or after January 1,
2024).'';
(C) by redesignating subsections (b) through (e) as
subsections (d) through (g), respectively;
(D) by inserting after subsection (a) the following
new subsections:
``(b) Manner of Coverage.--Coverage described in subsection (a)
shall be provided in a manner determined in consultation with the
attending physician and the patient and for which the patient is a
medical candidate. Such coverage may be subject to annual deductibles
and coinsurance provisions as are consistent with those established for
other benefits under the plan or coverage. Written notice of the
availability of such coverage shall be delivered to the participant
upon enrollment and annually thereafter.
``(c) In-Network Access.--A group health plan and a health
insurance issuer offering group health insurance coverage shall ensure
that at least 1 in-network provider is available under such plan or
coverage with respect to each modality, type of reconstruction, and
procedural variation, iteration, and approach described in subsection
(a).'';
(E) in subsection (d), as so redesignated, by
striking paragraphs (1) through (3) and inserting the
following new paragraphs:
``(1) upon such participant or beneficiary's enrollment in
such plan or coverage; and
``(2) as part of any yearly informational packet sent to
the participant or beneficiary thereafter.'';
(F) in subsection (e)(2), as so redesignated, by
inserting ``or with generally accepted standards of
medical practice'' before the period; and
(G) in subsection (g)(1), as so redesignated--
(i) by striking ``in effect on the date of
enactment of this section''; and
(ii) by striking ``reconstructive breast
surgery'' and inserting ``breast cancer care''.
(2) Clerical amendment.--The table of contents in section 1
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1001 note) is amended to read as follows:
``Sec. 713. Required coverage of certain items and services relating to
breast or chest wall reconstruction
furnished in connection with breast cancer
treatment.''.
(c) IRC.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new section:
``SEC. 9826. REQUIRED COVERAGE FOR CERTAIN ITEMS AND SERVICES RELATING
TO BREAST OR CHEST WALL RECONSTRUCTION FURNISHED IN
CONNECTION WITH BREAST CANCER TREATMENT.
``(a) In General.--A group health plan that provides medical and
surgical benefits with respect to the treatment of breast cancer shall
provide, in the case of a participant or beneficiary who is receiving
such treatment and who elects breast or chest wall reconstruction in
connection with such treatment, coverage for--
``(1) extirpation or medical treatment of diseased or
damaged breast tissue, including mastectomy and all forms of
breast-conserving surgery;
``(2) each modality of breast reconstruction, including--
``(A) implant-based reconstruction;
``(B) tissue-based reconstruction; and
``(C) any reconstruction modalities that are
developed subsequent to the date of the enactment of
this subsection and recognized within Level I of the
Healthcare Common Procedure Coding System;
``(3) within each modality specified in paragraph (2), each
type of breast reconstruction, including--
``(A) immediate implant-based reconstruction;
``(B) delayed implant-based reconstruction;
``(C) myocutaneous flap tissue-based
reconstruction;
``(D) microvascular free flap tissue-based
reconstruction; structural fat grafting tissue-based
reconstruction;
``(E) combined implant- and tissue-based
reconstruction; and
``(F) any type of reconstruction that is developed
subsequent to the effective date of this act and
incorporated within Level I of the Healthcare Common
Procedure Coding System;
``(4) within each type of breast reconstruction specified
in paragraph (3), each procedural variation, iteration, or
approach that is noted within the short descriptor or the
description for the Healthcare Common Procedure Coding System
Level I code covering the type of reconstruction;
``(5) all stages of reconstruction of the breast or chest
wall on which a mastectomy or breast-conserving surgery has
been performed, including flat closure;
``(6) surgery and reconstruction of the other breast or
chest wall to produce a symmetrical appearance;
``(7) custom fabricated breast prostheses, including
replacement of such prostheses; and
``(8) mechanical, medical, and surgical treatment of
physical complications of mastectomy, breast reconstruction
surgery, chest wall surgery, radiation, and lymph node surgery,
including lymphedema compression treatment items (as such term
is defined in section 1861(mmm) of the Social Security Act but
without regard to the requirement in paragraph (1) of such
section that such an item be furnished on or after January 1,
2024).
``(b) Manner of Coverage.--Coverage described in subsection (a)
shall be provided in a manner determined in consultation with the
attending physician and the patient and for which the patient is a
medical candidate. Such coverage may be subject to annual deductibles
and coinsurance provisions as are consistent with those established for
other benefits under the plan. Written notice of the availability of
such coverage shall be delivered to the participant or beneficiary upon
enrollment and annually thereafter.
``(c) In-Network Access.--A group health plan shall ensure that at
least 1 in-network provider is available under such plan with respect
to each modality, type of reconstruction, and procedural variation,
iteration, and approach described in subsection (a).
``(d) Notice.--A group health plan shall provide notice to each
participant and beneficiary under such plan regarding the coverage
required by this section in accordance with regulations promulgated by
the Secretary. Such notice shall be in writing and prominently
positioned in any literature or correspondence made available or
distributed by the plan or issuer and shall be transmitted--
``(1) upon such participant or beneficiary's enrollment in
such plan; and
``(2) as part of any yearly informational packet sent to
the participant or beneficiary thereafter.
``(e) Prohibitions.--A group health plan may not--
``(1) deny to a patient eligibility, or continued
eligibility, to enroll or to renew coverage under the terms of
the plan, solely for the purpose of avoiding the requirements
of this section; and
``(2) penalize or otherwise reduce or limit the
reimbursement of an attending provider, or provide incentives
(monetary or otherwise) to an attending provider, to induce
such provider to provide care to an individual participant or
beneficiary in a manner inconsistent with this section or with
generally accepted standards of medical practice.
``(f) Rule of Construction.--Nothing in this section shall be
construed to prevent a group health plan from negotiating the level and
type of reimbursement with a provider for care provided in accordance
with this section.
``(g) Preemption.--Nothing in this section shall be construed to
preempt any State law with respect to health insurance coverage that
requires coverage of at least the coverage of breast cancer care
otherwise required under this section.''.
(2) Clerical amendment.--The table of sections for such
subchapter is amended by inserting after the entry relating to
section 9825 the following:
``Sec. 9826. Required coverage for certain items and services relating
to breast or chest wall reconstruction
furnished in connection with breast cancer
treatment.''.
(d) Report.--Not later that 1 year after the date of the enactment
of this Act, the Comptroller General of the United States shall submit
to the appropriate committees of Congress a report describing any gaps
or barriers in access to breast reconstruction, including microsurgical
breast reconstruction.
(e) Effective Date.--
(1) In general.--The amendments made by this section shall
apply to plan years beginning on or after the date of the
enactment of this Act.
(2) Special rule for collective bargaining agreements.--In
the case of a group health plan maintained pursuant to 1 or
more collective bargaining agreements between employee
representatives and 1 or more employers, any plan amendment
made pursuant to a collective bargaining agreement relating to
the plan which amends the plan solely to conform to any
requirement added by this section shall not be treated as a
termination of such collective bargaining agreement.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
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