Access to Breast Cancer Diagnosis Act of 2025
- Sponsor
- Sen. Shaheen, Jeanne [D-NH]
- Committees
- Health, Education, Labor, and Pensions Committee (primary)
- Last action
- Apr 28, 2025
Bottom line
This bill aims to eliminate out-of-pocket costs for medically necessary breast cancer diagnostic and supplemental imaging, potentially increasing access and reducing financial barriers for individuals.
What it actually does
This bill amends the Public Health Service Act to prohibit group health plans and health insurance issuers from imposing any cost-sharing requirements, such as deductibles, copayments, or coinsurance, for diagnostic and supplemental breast examinations. It defines these examinations based on medical necessity and National Comprehensive Cancer Network Guidelines, and extends this prohibition to grandfathered health plans and creates a safe harbor for high-deductible health plans to ensure HSA eligibility is not affected.
Proponents argue
Supporters argue this bill removes significant financial barriers to crucial breast cancer diagnostic services, ensuring that individuals, especially those with higher risk factors or suspicious findings, can access necessary follow-up care without facing unexpected costs. This could lead to earlier detection, better health outcomes, and reduced disparities in care by preventing delays in diagnosis due to financial concerns.
Opponents contend
Opponents might argue that mandating zero cost-sharing could increase premiums for all enrollees, shifting costs to other areas of healthcare or increasing the overall cost of health insurance. They might also raise concerns about potential overutilization of services if there are no financial deterrents, even with the allowance for prior authorization.
The bill is concise and can be read quickly, allowing ample time for evaluation of its implications.
Section 1
Short Title
This section establishes the official short title of the Act as the "Access to Breast Cancer Diagnosis Act of 2025," which is how the bill will be commonly referred to if enacted. This provides a clear and concise name for the legislation, aiding in public understanding and legislative tracking.
Supporters argue
A clear short title helps with public understanding and legislative tracking of the bill's purpose, making it easier for stakeholders and the public to refer to and discuss the legislation.
Critics contend
No specific opposition is typically raised against short title provisions, as they are standard legislative practice.
Tradeoffs
None apparent for a short title.
Section 2(a), adding new section 2730(a) to the Public Health Service Act.
Prohibition on Cost-Sharing for Breast Examinations
This core provision mandates that group health plans and health insurance issuers cannot impose deductibles, coinsurance, copayments, or similar out-of-pocket expenses for diagnostic and supplemental breast examinations if they already cover these benefits. This means patients would not pay anything directly for these specific services, aiming to remove financial barriers to necessary care.
Section 2(a), adding new section 2730(b) and (c) to the Public Health Service Act.
Clarifications and Definitions for Breast Examinations
This part clarifies that health plans can still require prior authorization or other utilization controls for these examinations, and that state laws offering greater protections are not superseded. It defines "cost-sharing requirements" to include deductibles, coinsurance, copayments, and similar out-of-pocket expenses. Crucially, it defines "diagnostic breast examination" and "supplemental breast examination" based on medical necessity and National Comprehensive Cancer Network Guidelines, specifying types like mammography, MRI, and ultrasound.
Section 2(b), amending Section 1251(a)(4)(A) of the Patient Protection and Affordable Care Act.
Inclusion of Grandfathered Plans
This section extends the new cost-sharing prohibition for diagnostic and supplemental breast examinations to "grandfathered" health plans. These are plans that existed before the Affordable Care Act (ACA) and are generally exempt from many ACA requirements, but this amendment specifically brings them under the purview of the new no-cost-sharing rule for these breast examinations.
Section 2(c), amending Section 223(c)(2) of the Internal Revenue Code of 1986.
Safe Harbor for HDHPs and HSAs
This section creates a "safe harbor" for high-deductible health plans (HDHPs) starting January 1, 2026. It specifies that an HDHP will not lose its status (and thus its enrollees' eligibility for Health Savings Accounts, HSAs) simply because it covers diagnostic and supplemental breast examinations without a deductible. This is important because HDHPs typically require a high deductible to be met before most services are covered.
Section 2(b) extends the no-cost-sharing requirement to grandfathered health plans, which are typically exempt from many ACA mandates. Section 2(c) creates a safe harbor for high-deductible health plans (HDHPs), allowing them to cover these examinations without a deductible while maintaining HSA eligibility.
Section 2(b) and 2(c)
Why it matters:This is standard legislative practice for amending existing complex legal frameworks like the ACA and IRS Code. It ensures the new policy integrates correctly with existing law.
Case for: Supporters argue these provisions are essential to ensure the new no-cost-sharing benefit is broadly applicable across different types of health plans, preventing gaps in coverage and ensuring fairness for all insured individuals, including those in grandfathered plans or HDHPs.
Case against: Critics might argue that these amendments incrementally chip away at the distinct regulatory categories of grandfathered plans and HDHPs, potentially leading to increased complexity or unintended consequences for these specific plan types.
Estimated impact: These provisions significantly broaden the reach of the no-cost-sharing mandate, affecting millions of individuals enrolled in grandfathered plans or HDHPs, and impacting the design and administration of these plans by insurers.