S1500-119

1. Short title This Act may be cited as the Access to Breast Cancer Diagnosis Act of 2025.

2. Requiring diagnostic and supplemental breast examinations to be covered with no cost-sharing requirements Subpart II of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–11 et seq.) is amended by adding at the end the following new section: In the case of a group health plan, or a health insurance issuer offering group or individual health insurance coverage, that provides benefits with respect to diagnostic and supplemental breast examinations furnished to an individual enrolled under such plan or such coverage, such plan or coverage shall not impose any cost-sharing requirements for these benefits. Nothing in this section shall be construed— to prohibit a group health plan or health insurance issuer from requiring timely prior authorization or imposing other appropriate utilization controls in approving coverage for any diagnostic and supplemental breast examination; or to supersede a State law that provides greater protections with respect to the coverage of diagnostic and supplemental breast examinations than is provided under this section. In this section: The term cost-sharing requirements means a deductible, coinsurance, copayment, and any maximum limitation on the application of such a deductible, coinsurance, copayment or similar out-of-pocket expense. The term diagnostic breast examination means a medically necessary and appropriate (in accordance with National Comprehensive Cancer Network Guidelines) examination of the breast (including, but not limited to such an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound) that is— used to evaluate an abnormality seen or suspected from a screening examination for breast cancer; or used to evaluate an abnormality detected by another means of examination. The term supplemental breast examination means a medically necessary and appropriate (in accordance with National Comprehensive Cancer Network Guidelines) examination of the breast (including, but not limited to such an examination using breast magnetic resonance imaging or breast ultrasound) that is— used to screen for breast cancer when there is no abnormality seen or suspected; and furnished based on personal or family medical history or additional factors that may increase the individual’s risk of breast cancer. Section 1251(a)(4)(A) of the Patient Protection and Affordable Care Act (42 U.S.C. 18011(a)(4)(A)) is amended— by striking title and inserting title, or as added after the date of the enactment of this Act; and by adding at the end the following new clause: Section 2730 (relating to coverage for diagnostic and supplemental breast examinations). Section 223(c)(2) of the Internal Revenue Code of 1986 is amended by adding at the end the following: In the case of plan years beginning on or after January 1, 2026, a plan shall not fail to be treated as a high deductible health plan by reason of failing to have a deductible for diagnostic and supplemental breast examinations. The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2026. 2730.Diagnostic and supplemental breast examinations(a)In generalIn the case of a group health plan, or a health insurance issuer offering group or individual health insurance coverage, that provides benefits with respect to diagnostic and supplemental breast examinations furnished to an individual enrolled under such plan or such coverage, such plan or coverage shall not impose any cost-sharing requirements for these benefits. (b)ConstructionNothing in this section shall be construed—(1)to prohibit a group health plan or health insurance issuer from requiring timely prior authorization or imposing other appropriate utilization controls in approving coverage for any diagnostic and supplemental breast examination; or(2)to supersede a State law that provides greater protections with respect to the coverage of diagnostic and supplemental breast examinations than is provided under this section.(c)DefinitionsIn this section:(1)Cost-sharing requirementsThe term cost-sharing requirements means a deductible, coinsurance, copayment, and any maximum limitation on the application of such a deductible, coinsurance, copayment or similar out-of-pocket expense.(2)Diagnostic breast examinationThe term diagnostic breast examination means a medically necessary and appropriate (in accordance with National Comprehensive Cancer Network Guidelines) examination of the breast (including, but not limited to such an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound) that is—(A)used to evaluate an abnormality seen or suspected from a screening examination for breast cancer; or(B)used to evaluate an abnormality detected by another means of examination.(3)Supplemental breast examinationsThe term supplemental breast examination means a medically necessary and appropriate (in accordance with National Comprehensive Cancer Network Guidelines) examination of the breast (including, but not limited to such an examination using breast magnetic resonance imaging or breast ultrasound) that is—(A)used to screen for breast cancer when there is no abnormality seen or suspected; and(B)furnished based on personal or family medical history or additional factors that may increase the individual’s risk of breast cancer.. (v)Section 2730 (relating to coverage for diagnostic and supplemental breast examinations).. (H)Safe harbor for absence of deductible for diagnostic and supplemental breast examinationsIn the case of plan years beginning on or after January 1, 2026, a plan shall not fail to be treated as a high deductible health plan by reason of failing to have a deductible for diagnostic and supplemental breast examinations..

2730. Diagnostic and supplemental breast examinations In the case of a group health plan, or a health insurance issuer offering group or individual health insurance coverage, that provides benefits with respect to diagnostic and supplemental breast examinations furnished to an individual enrolled under such plan or such coverage, such plan or coverage shall not impose any cost-sharing requirements for these benefits. Nothing in this section shall be construed— to prohibit a group health plan or health insurance issuer from requiring timely prior authorization or imposing other appropriate utilization controls in approving coverage for any diagnostic and supplemental breast examination; or to supersede a State law that provides greater protections with respect to the coverage of diagnostic and supplemental breast examinations than is provided under this section. In this section: The term cost-sharing requirements means a deductible, coinsurance, copayment, and any maximum limitation on the application of such a deductible, coinsurance, copayment or similar out-of-pocket expense. The term diagnostic breast examination means a medically necessary and appropriate (in accordance with National Comprehensive Cancer Network Guidelines) examination of the breast (including, but not limited to such an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound) that is— used to evaluate an abnormality seen or suspected from a screening examination for breast cancer; or used to evaluate an abnormality detected by another means of examination. The term supplemental breast examination means a medically necessary and appropriate (in accordance with National Comprehensive Cancer Network Guidelines) examination of the breast (including, but not limited to such an examination using breast magnetic resonance imaging or breast ultrasound) that is— used to screen for breast cancer when there is no abnormality seen or suspected; and furnished based on personal or family medical history or additional factors that may increase the individual’s risk of breast cancer.