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Revises paragraph (ddd)(1)(B) by reorganizing the existing text (making prior text (B) into (B)(i)), changing connector language, and adding a new clause (ii) that, beginning January 1, 2026, requires coverage of screening and diagnostic breast imaging (with no limitation on frequency) for specified individuals (those at increased risk or with dense breasts, and those determined by a provider per specified criteria).
Amends subsection (a) (medical assistance) by making adjustments to paragraph (4) punctuation/structure and inserting material in paragraph (13) to accommodate inclusion of coverage for certain breast cancer screening and diagnostic imaging described elsewhere in the Act.
Adds a new subparagraph (K) to subsections (a)(2) and (b)(2) of section 1916 to require that, with respect to individuals described in clause (i) or (ii) of section 1905(a)(4)(G), screening and diagnostic imaging (and related technologies) described in such clause be treated under the cost-sharing rules (i.e., added to the list of items/services exempted from certain cost sharing).
Modifies section 1251(a)(4)(A) of the Affordable Care Act (42 U.S.C. 18011(a)(4)(A)) to expand the clause describing grandfathered plans so that the new breast screening requirement in section 2713(a)(1)(E) (screening and diagnostic imaging for the detection of breast cancer) is treated as a provision that may apply to grandfathered health plans (inserting a reference to provisions 'added after the date of the enactment of this Act' and adding the new clause referencing section 2713(a)(1)(E)).
Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
Introduced April 10, 2025 by Amy Klobuchar · Last progress April 10, 2025
Requires insurers and federal health programs to eliminate cost-sharing for extra breast cancer screening and diagnostic imaging when a person is at increased risk, has dense breast tissue, or a clinician determines additional screening is needed for reasons such as age, race, ethnicity, or family history. The rule applies across group and individual health plans, Medicare (including Medicare Advantage), Medicaid, TRICARE, and veterans’ benefits, with most changes effective January 1, 2026.
Amend Section 2713(a) of the Public Health Service Act to require group health plans and group and individual market coverage to cover, with no cost-sharing, screening and diagnostic breast imaging (no frequency limit) — including 2D/3D mammograms, breast ultrasounds, breast MRI, molecular breast imaging, or other technologies — for individuals at increased risk of breast cancer or with heterogeneously or extremely dense breast tissue, and for individuals a health care provider determines require such imaging because of factors like age, race, ethnicity, or personal/family history.
The amendments to group health plan and individual market coverage apply to plan years beginning on or after January 1, 2026.
Amend Patient Protection and Affordable Care Act section 1251(a)(4)(A) to clarify application to grandfathered health plans for the new breast imaging coverage requirement.
Amend Section 1861(ddd)(1)(B) of the Social Security Act to add, beginning January 1, 2026, a clause requiring Medicare to cover (with no limitation on frequency) screening and diagnostic breast imaging for individuals at increased risk or with heterogeneously/extremely dense breast tissue, and for individuals a provider determines require such imaging because of factors determined by the Secretary (including age, race, ethnicity, or personal/family medical history).
Amend Medicare Advantage rules (section 1852(a)(1)(B)) to require that, beginning January 1, 2026, screening and diagnostic imaging described in the Medicare amendment be furnished to individuals described in that Medicare provision.
Who is affected and how:
People at increased risk of breast cancer and people with dense breast tissue: They will no longer face copays, coinsurance, or deductibles for additional screening and diagnostic breast imaging that their clinician determines is needed. This reduces financial barriers and may speed diagnosis.
Women and other people who receive breast screening: Greater access to timely follow-up imaging could increase detection of cancer earlier among higher-risk groups.
Private insurers and group health plans: Must change plan benefit designs and claims systems to cover extra imaging without patient cost-sharing; this could raise plan costs depending on changes in utilization.
Federal programs (Medicare, Medicaid, TRICARE, VA benefits): Agencies will need to update coverage rules and payment procedures; Medicaid program changes may require state plan adjustments or guidance, depending on how the change is implemented.
Health care providers and imaging centers: May see increased referrals for diagnostic imaging and will need to coordinate with payers to ensure services are billed correctly with no patient cost-sharing.
Budget and administrative effects: The legislation mandates coverage but does not appropriate funds or set payment levels; potential increases in payer expenditures and administrative burdens are expected but not quantified in the text.
Expand sections to see detailed analysis
Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
Introduced in Senate