Access to Breast Cancer Diagnosis Act of 2025
- Sponsor
- Rep. Dingell, Debbie [D-MI-6]
- Committees
- Ways and Means Committee (primary)
- Last action
- Apr 28, 2025
Bottom line
The Access to Breast Cancer Diagnosis Act of 2025 aims to eliminate out-of-pocket costs for medically necessary diagnostic and supplemental breast examinations, thereby reducing financial barriers to critical cancer detection.
What it actually does
This bill mandates that group health plans and health insurance issuers cannot impose cost-sharing requirements, such as deductibles, copayments, or coinsurance, for diagnostic and supplemental breast examinations. It also ensures that high-deductible health plans can cover these services without a deductible while maintaining eligibility for health savings accounts, and extends these protections to grandfathered health plans.
Proponents argue
Proponents argue that eliminating cost-sharing for diagnostic and supplemental breast examinations will remove significant financial barriers that often delay or prevent individuals from receiving necessary follow-up care after an initial screening or due to increased risk factors. They contend this will lead to earlier detection of breast cancer, improved health outcomes, and ultimately lower overall healthcare costs by reducing the need for more extensive and expensive treatments for advanced cancers.
Opponents contend
Opponents might argue that mandating zero cost-sharing for these services could increase premiums for all enrollees, as the costs would be absorbed by the health plans and passed on. They may also express concerns about potential overutilization of services if there are no financial deterrents, though the bill does allow for prior authorization and utilization controls.
The bill is concise and straightforward, allowing for a quick read and understanding of its core provisions.
Section 2(a), adding new Section 2730(a) to the Public Health Service Act.
Mandate for Zero Cost-Sharing on Breast Examinations
This provision prohibits health insurance plans from charging patients any deductibles, copayments, or coinsurance for medically necessary diagnostic and supplemental breast examinations. This means individuals would not have to pay out-of-pocket costs at the time of service for tests like diagnostic mammograms, breast MRIs, or ultrasounds used to investigate abnormalities or screen high-risk individuals.
Supporters argue
Supporters argue this provision is crucial for equitable access to breast cancer diagnosis, preventing individuals from delaying or foregoing essential tests due to financial concerns. They believe it will save lives through earlier detection.
Critics contend
Critics might contend that while the intent is good, shifting all costs to plans will inevitably lead to higher premiums for all policyholders, effectively spreading the cost rather than eliminating it, potentially making insurance less affordable for some.
Tradeoffs
The primary tradeoff is between reducing individual out-of-pocket costs at the point of care and potentially increasing overall premium costs for all insured individuals.
Section 2(a), adding new Section 2730(b) to the Public Health Service Act.
Preservation of Prior Authorization and State Protections
This section clarifies that while cost-sharing is prohibited, health plans can still require prior authorization or other appropriate utilization controls for diagnostic and supplemental breast examinations. It also ensures that any existing state laws offering greater protections for breast examination coverage will not be superseded by this federal act.
Section 2(a), adding new Section 2730(c) to the Public Health Service Act.
Standardized Definitions for Covered Examinations
This section provides precise definitions for "cost-sharing requirements," "diagnostic breast examination," and "supplemental breast examination." It specifies that these examinations must be "medically necessary and appropriate (in accordance with National Comprehensive Cancer Network Guidelines)" and lists examples like diagnostic mammography, breast MRI, and breast ultrasound for specific purposes.
Section 2(b)
Inclusion of Grandfathered Health Plans
This provision amends the Patient Protection and Affordable Care Act (ACA) to ensure that the new requirement for zero cost-sharing on diagnostic and supplemental breast examinations also applies to "grandfathered" health plans. These are plans that existed before the ACA's enactment and are generally exempt from many of its requirements, but this amendment brings them under this specific mandate.
Section 2(c)
HSA-Eligible HDHP Safe Harbor for Breast Examinations
This provision amends the Internal Revenue Code to allow High Deductible Health Plans (HDHPs) to cover diagnostic and supplemental breast examinations without a deductible, starting January 1, 2026, without losing their status as an HDHP. This is crucial because individuals must be enrolled in an HDHP to be eligible for a Health Savings Account (HSA), and typically, HDHPs cannot cover any benefits before the deductible is met (with some exceptions for preventive care).
Extends the no-cost-sharing mandate for diagnostic and supplemental breast examinations to grandfathered health plans, which are typically exempt from many ACA requirements.
Section 2(b)
Why it matters:This is standard legislative practice for applying new mandates to specific categories of plans that have different regulatory treatment. It's a technical amendment to ensure comprehensive coverage.
Case for: Supporters argue that it ensures equitable access to critical breast cancer diagnostic services for all insured individuals, regardless of their plan's grandfathered status, preventing a two-tiered system of care.
Case against: Critics of expanding mandates to grandfathered plans might argue that it further erodes the regulatory stability these plans were intended to have, potentially increasing their costs and administrative burden.
Estimated impact: Extends coverage to an estimated several million individuals still enrolled in grandfathered plans.
Amends the Internal Revenue Code to allow High Deductible Health Plans (HDHPs) to cover diagnostic and supplemental breast examinations without a deductible, without jeopardizing a participant's eligibility for a Health Savings Account (HSA).
Section 2(c)
Why it matters:This is a necessary technical adjustment to reconcile the new health insurance mandate with existing tax law governing HSAs, ensuring the primary policy goal can be achieved without unintended negative consequences for a significant portion of the insured population.
Case for: Proponents argue this is a critical technical fix to ensure that individuals with HDHPs can access these vital diagnostic services without financial barriers, while still benefiting from their HSAs. Without it, the primary mandate could inadvertently harm HSA users.
Case against: No significant case against this specific technical fix, as it facilitates the broader policy goal.
Estimated impact: Affects millions of individuals enrolled in HDHPs, ensuring their continued HSA eligibility while accessing breast exams.