Sponsors (14)
Requires group health plans and issuers that cover breast cancer treatment to also cover a comprehensive set of breast/chest reconstruction services and related items when elected by the patient.
The bill expands guaranteed, patient-centered coverage and provider access for breast/chest reconstruction, improving care and choice for people with breast cancer, but it may raise plan and employer costs, leave some patients facing out-of-pocket charges, and fail to fully resolve access gaps in underserved areas.
Women and people with breast cancer gain guaranteed coverage for comprehensive breast/chest wall reconstruction (implants, flap procedures, prostheses, lymphedema supplies) under group and individual plans.
Patients (people with breast cancer) can make reconstruction decisions in consultation with their attending physician and be medically evaluated for candidacy without plan interference.
Plans must ensure at least one in‑network provider is available for each reconstruction modality/type/variation, improving timely access to covered reconstruction services for beneficiaries.
Insurers and employers may face higher costs to expand network capacity and cover more procedures and supplies, which could lead to higher premiums or increased employer plan costs for taxpayers, families, and businesses.
Patients can still be subject to annual deductibles and coinsurance for reconstruction, leaving many with potentially significant out‑of‑pocket costs for complex procedures.
In areas lacking specialists (e.g., microsurgical reconstruction), compliance may be difficult and real-world access may remain limited despite the mandate, harming rural and underserved patients.
Based on analysis of 2 sections of legislative text.
Official title: 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.
Introduced October 24, 2025 by Kat Cammack · Last progress October 24, 2025
Requires group health plans and health insurance issuers that cover breast cancer treatment to also cover a broad, modern set of breast and chest wall reconstruction items and services when a patient elects reconstruction connected to treatment. Coverage includes all reconstruction modalities and stages, symmetry surgery, custom prostheses, treatment of complications (including lymphedema items), notice requirements, network access standards, and protections against plan design or provider incentives that would limit medically appropriate care. The rule applies to plan years beginning on or after enactment and directs the Comptroller General to report within one year on access gaps and barriers.