H.R. 5813

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5813 Introduced in House (IH)]

<DOC>

119th CONGRESS
1st Session
H. R. 5813

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.

_______________________________________________________________________

IN THE HOUSE OF REPRESENTATIVES

October 24, 2025

Mrs. Cammack (for herself, Mrs. Dingell, Mrs. Hinson, Mrs. McBath, Mrs. 
Kim, Mrs. McClain Delaney, Ms. Van Duyne, Ms. Perez, and Ms. Pettersen) 
introduced the following bill; which was referred to the Committee on 
Energy and Commerce, and in addition to the Committees on Ways and 
Means, and Education and Workforce, for a period to be subsequently 
determined by the Speaker, in each case for consideration of such 
provisions as fall within the jurisdiction of the committee concerned

_______________________________________________________________________

A BILL

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.

Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ``Women's Health and Cancer Rights 
Modernization Act of 2025''.

SEC. 2. REQUIRING COVERAGE OF CERTAIN ITEMS AND SERVICES RELATING TO 
BREAST OR CHEST WALL RECONSTRUCTION FURNISHED IN 
CONNECTION WITH BREAST CANCER TREATMENT.

(a) PHSA.--
(1) In general.--Part D of title XXVII of the Public Health 
Service Act (42 U.S.C. 300gg-111 et seq.) is amended by adding 
at the end the following new section:

``SEC. 2799A-11. REQUIRED COVERAGE FOR CERTAIN ITEMS AND SERVICES 
RELATING TO BREAST OR CHEST WALL RECONSTRUCTION FURNISHED 
IN CONNECTION WITH BREAST CANCER TREATMENT.

``(a) In General.--A group health plan, and a health insurance 
issuer offering group or individual health insurance coverage, that 
provides medical and surgical benefits with respect to the treatment of 
breast cancer shall provide, in the case of a participant or 
beneficiary who is receiving such treatment and who elects breast or 
chest wall reconstruction in connection with such treatment, coverage 
for--
``(1) extirpation or medical treatment of diseased or 
damaged breast tissue, including mastectomy and all forms of 
breast-conserving surgery;
``(2) each modality of breast reconstruction, including--
``(A) implant-based reconstruction;
``(B) tissue-based reconstruction; and
``(C) any reconstruction modalities that are 
developed subsequent to the date of the enactment of 
this subsection and recognized within Level I of the 
Healthcare Common Procedure Coding System;
``(3) within each modality specified in paragraph (2), each 
type of breast reconstruction, including--
``(A) immediate implant-based reconstruction;
``(B) delayed implant-based reconstruction;
``(C) myocutaneous flap tissue-based 
reconstruction;
``(D) microvascular free flap tissue-based 
reconstruction; structural fat grafting tissue-based 
reconstruction;
``(E) combined implant- and tissue-based 
reconstruction; and
``(F) any type of reconstruction that is developed 
subsequent to the effective date of this act and 
incorporated within Level I of the Healthcare Common 
Procedure Coding System;
``(4) within each type of breast reconstruction specified 
in paragraph (3), each procedural variation, iteration, or 
approach that is noted within the short descriptor or the 
description for the Healthcare Common Procedure Coding System 
Level I code covering the type of reconstruction;
``(5) all stages of reconstruction of the breast or chest 
wall on which a mastectomy or breast-conserving surgery has 
been performed, including flat closure;
``(6) surgery and reconstruction of the other breast or 
chest wall to produce a symmetrical appearance;
``(7) custom fabricated breast prostheses, including 
replacement of such prostheses; and
``(8) mechanical, medical, and surgical treatment of 
physical complications of mastectomy, breast reconstruction 
surgery, chest wall surgery, radiation, and lymph node surgery, 
including lymphedema compression treatment items (as such term 
is defined in section 1861(mmm) of the Social Security Act but 
without regard to the requirement in paragraph (1) of such 
section that such an item be furnished on or after January 1, 
2024).
``(b) Manner of Coverage.--Coverage described in subsection (a) 
shall be provided in a manner determined in consultation with the 
attending physician and the patient and for which the patient is a 
medical candidate. Such coverage may be subject to annual deductibles 
and coinsurance provisions as are consistent with those established for 
other benefits under the plan or coverage. Written notice of the 
availability of such coverage shall be delivered to the participant 
upon enrollment and annually thereafter.
``(c) In-Network Access.--A group health plan and a health 
insurance issuer offering group or individual health insurance coverage 
shall ensure that at least 1 in-network provider is available under 
such plan or coverage with respect to each modality, type of 
reconstruction, and procedural variation, iteration, and approach 
described in subsection (a).
``(d) Notice.--A group health plan, and a health insurance issuer 
offering group or individual health insurance coverage, shall provide 
notice to each individual enrolled under such plan regarding the 
coverage required by this section in accordance with regulations 
promulgated by the Secretary. Such notice shall be in writing and 
prominently positioned in any literature or correspondence made 
available or distributed by the plan or issuer and shall be 
transmitted--
``(1) upon such individual's enrollment in such plan or 
coverage; and
``(2) as part of any yearly informational packet sent to 
the individual thereafter.
``(e) Prohibitions.--A group health plan, and a health insurance 
issuer offering group or individual health insurance coverage, may 
not--
``(1) deny to a patient eligibility, or continued 
eligibility, to enroll or to renew coverage under the terms of 
the plan, solely for the purpose of avoiding the requirements 
of this section; and
``(2) penalize or otherwise reduce or limit the 
reimbursement of an attending provider, or provide incentives 
(monetary or otherwise) to an attending provider, to induce 
such provider to provide care to an individual participant or 
beneficiary in a manner inconsistent with this section or with 
generally accepted standards of medical practice.
``(f) Rule of Construction.--Nothing in this section shall be 
construed to prevent a group health plan or a health insurance issuer 
offering group or individual health insurance coverage from negotiating 
the level and type of reimbursement with a provider for care provided 
in accordance with this section.
``(g) Preemption.--Nothing in this section shall be construed to 
preempt any State law with respect to health insurance coverage that 
requires coverage of at least the coverage of breast cancer care 
otherwise required under this section.''.
(2) Conforming amendment.--Section 2727 of the Public 
Health Service Act (42 U.S.C. 300gg-27) is amended by adding at 
the end the following new sentence: ``The preceding sentence 
shall not apply with respect to plan years beginning on or 
after the date of the enactment of this sentence.''.
(b) ERISA.--
(1) In general.--Section 713 of the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 1185b) is amended--
(A) in the header, by striking ``reconstructive 
surgery following mastectomies'' and inserting 
``certain items and services relating to breast or 
chest wall reconstruction furnished in connection with 
breast cancer treatment'';
(B) by amending subsection (a) to read as follows:
``(a) In General.--A group health plan, and a health insurance 
issuer providing health insurance coverage in connection with a group 
health plan, that provides medical and surgical benefits with respect 
to the treatment of breast cancer shall provide, in the case of a 
participant or beneficiary who is receiving such treatment and who 
elects breast or chest wall reconstruction in connection with such 
treatment, coverage for--
``(1) extirpation or medical treatment of diseased or 
damaged breast tissue, including mastectomy and all forms of 
breast-conserving surgery;
``(2) each modality of breast reconstruction, including--
``(A) implant-based reconstruction;
``(B) tissue-based reconstruction; and
``(C) any reconstruction modalities that are 
developed subsequent to the date of the enactment of 
this subsection and recognized within Level I of the 
Healthcare Common Procedure Coding System;
``(3) within each modality specified in paragraph (2), each 
type of breast reconstruction, including--
``(A) immediate implant-based reconstruction;
``(B) delayed implant-based reconstruction;
``(C) myocutaneous flap tissue-based 
reconstruction;
``(D) microvascular free flap tissue-based 
reconstruction; structural fat grafting tissue-based 
reconstruction;
``(E) combined implant- and tissue-based 
reconstruction; and
``(F) any type of reconstruction that is developed 
subsequent to the effective date of this act and 
incorporated within Level I of the Healthcare Common 
Procedure Coding System;
``(4) within each type of breast reconstruction specified 
in paragraph (3), each procedural variation, iteration, or 
approach that is noted within the short descriptor or the 
description for the Healthcare Common Procedure Coding System 
Level I code covering the type of reconstruction;
``(5) all stages of reconstruction of the breast or chest 
wall on which a mastectomy or breast-conserving surgery has 
been performed, including flat closure;
``(6) surgery and reconstruction of the other breast or 
chest wall to produce a symmetrical appearance;
``(7) custom fabricated breast prostheses, including 
replacement of such prostheses; and
``(8) mechanical, medical, and surgical treatment of 
physical complications of mastectomy, breast reconstruction 
surgery, chest wall surgery, radiation, and lymph node surgery, 
including lymphedema compression treatment items (as such term 
is defined in section 1861(mmm) of the Social Security Act but 
without regard to the requirement in paragraph (1) of such 
section that such an item be furnished on or after January 1, 
2024).'';
(C) by redesignating subsections (b) through (e) as 
subsections (d) through (g), respectively;
(D) by inserting after subsection (a) the following 
new subsections:
``(b) Manner of Coverage.--Coverage described in subsection (a) 
shall be provided in a manner determined in consultation with the 
attending physician and the patient and for which the patient is a 
medical candidate. Such coverage may be subject to annual deductibles 
and coinsurance provisions as are consistent with those established for 
other benefits under the plan or coverage. Written notice of the 
availability of such coverage shall be delivered to the participant 
upon enrollment and annually thereafter.
``(c) In-Network Access.--A group health plan and a health 
insurance issuer offering group health insurance coverage shall ensure 
that at least 1 in-network provider is available under such plan or 
coverage with respect to each modality, type of reconstruction, and 
procedural variation, iteration, and approach described in subsection 
(a).'';
(E) in subsection (d), as so redesignated, by 
striking paragraphs (1) through (3) and inserting the 
following new paragraphs:
``(1) upon such participant or beneficiary's enrollment in 
such plan or coverage; and
``(2) as part of any yearly informational packet sent to 
the participant or beneficiary thereafter.'';
(F) in subsection (e)(2), as so redesignated, by 
inserting ``or with generally accepted standards of 
medical practice'' before the period; and
(G) in subsection (g)(1), as so redesignated--
(i) by striking ``in effect on the date of 
enactment of this section''; and
(ii) by striking ``reconstructive breast 
surgery'' and inserting ``breast cancer care''.
(2) Clerical amendment.--The table of contents in section 1 
of the Employee Retirement Income Security Act of 1974 (29 
U.S.C. 1001 note) is amended to read as follows:

``Sec. 713. Required coverage of certain items and services relating to 
breast or chest wall reconstruction 
furnished in connection with breast cancer 
treatment.''.
(c) IRC.--
(1) In general.--Subchapter B of chapter 100 of the 
Internal Revenue Code of 1986 is amended by adding at the end 
the following new section:

``SEC. 9826. REQUIRED COVERAGE FOR CERTAIN ITEMS AND SERVICES RELATING 
TO BREAST OR CHEST WALL RECONSTRUCTION FURNISHED IN 
CONNECTION WITH BREAST CANCER TREATMENT.

``(a) In General.--A group health plan that provides medical and 
surgical benefits with respect to the treatment of breast cancer shall 
provide, in the case of a participant or beneficiary who is receiving 
such treatment and who elects breast or chest wall reconstruction in 
connection with such treatment, coverage for--
``(1) extirpation or medical treatment of diseased or 
damaged breast tissue, including mastectomy and all forms of 
breast-conserving surgery;
``(2) each modality of breast reconstruction, including--
``(A) implant-based reconstruction;
``(B) tissue-based reconstruction; and
``(C) any reconstruction modalities that are 
developed subsequent to the date of the enactment of 
this subsection and recognized within Level I of the 
Healthcare Common Procedure Coding System;
``(3) within each modality specified in paragraph (2), each 
type of breast reconstruction, including--
``(A) immediate implant-based reconstruction;
``(B) delayed implant-based reconstruction;
``(C) myocutaneous flap tissue-based 
reconstruction;
``(D) microvascular free flap tissue-based 
reconstruction; structural fat grafting tissue-based 
reconstruction;
``(E) combined implant- and tissue-based 
reconstruction; and
``(F) any type of reconstruction that is developed 
subsequent to the effective date of this act and 
incorporated within Level I of the Healthcare Common 
Procedure Coding System;
``(4) within each type of breast reconstruction specified 
in paragraph (3), each procedural variation, iteration, or 
approach that is noted within the short descriptor or the 
description for the Healthcare Common Procedure Coding System 
Level I code covering the type of reconstruction;
``(5) all stages of reconstruction of the breast or chest 
wall on which a mastectomy or breast-conserving surgery has 
been performed, including flat closure;
``(6) surgery and reconstruction of the other breast or 
chest wall to produce a symmetrical appearance;
``(7) custom fabricated breast prostheses, including 
replacement of such prostheses; and
``(8) mechanical, medical, and surgical treatment of 
physical complications of mastectomy, breast reconstruction 
surgery, chest wall surgery, radiation, and lymph node surgery, 
including lymphedema compression treatment items (as such term 
is defined in section 1861(mmm) of the Social Security Act but 
without regard to the requirement in paragraph (1) of such 
section that such an item be furnished on or after January 1, 
2024).
``(b) Manner of Coverage.--Coverage described in subsection (a) 
shall be provided in a manner determined in consultation with the 
attending physician and the patient and for which the patient is a 
medical candidate. Such coverage may be subject to annual deductibles 
and coinsurance provisions as are consistent with those established for 
other benefits under the plan. Written notice of the availability of 
such coverage shall be delivered to the participant or beneficiary upon 
enrollment and annually thereafter.
``(c) In-Network Access.--A group health plan shall ensure that at 
least 1 in-network provider is available under such plan with respect 
to each modality, type of reconstruction, and procedural variation, 
iteration, and approach described in subsection (a).
``(d) Notice.--A group health plan shall provide notice to each 
participant and beneficiary under such plan regarding the coverage 
required by this section in accordance with regulations promulgated by 
the Secretary. Such notice shall be in writing and prominently 
positioned in any literature or correspondence made available or 
distributed by the plan or issuer and shall be transmitted--
``(1) upon such participant or beneficiary's enrollment in 
such plan; and
``(2) as part of any yearly informational packet sent to 
the participant or beneficiary thereafter.
``(e) Prohibitions.--A group health plan may not--
``(1) deny to a patient eligibility, or continued 
eligibility, to enroll or to renew coverage under the terms of 
the plan, solely for the purpose of avoiding the requirements 
of this section; and
``(2) penalize or otherwise reduce or limit the 
reimbursement of an attending provider, or provide incentives 
(monetary or otherwise) to an attending provider, to induce 
such provider to provide care to an individual participant or 
beneficiary in a manner inconsistent with this section or with 
generally accepted standards of medical practice.
``(f) Rule of Construction.--Nothing in this section shall be 
construed to prevent a group health plan from negotiating the level and 
type of reimbursement with a provider for care provided in accordance 
with this section.
``(g) Preemption.--Nothing in this section shall be construed to 
preempt any State law with respect to health insurance coverage that 
requires coverage of at least the coverage of breast cancer care 
otherwise required under this section.''.
(2) Clerical amendment.--The table of sections for such 
subchapter is amended by inserting after the entry relating to 
section 9825 the following:

``Sec. 9826. Required coverage for certain items and services relating 
to breast or chest wall reconstruction 
furnished in connection with breast cancer 
treatment.''.
(d) Report.--Not later that 1 year after the date of the enactment 
of this Act, the Comptroller General of the United States shall submit 
to the appropriate committees of Congress a report describing any gaps 
or barriers in access to breast reconstruction, including microsurgical 
breast reconstruction.
(e) Effective Date.--
(1) In general.--The amendments made by this section shall 
apply to plan years beginning on or after the date of the 
enactment of this Act.
(2) Special rule for collective bargaining agreements.--In 
the case of a group health plan maintained pursuant to 1 or 
more collective bargaining agreements between employee 
representatives and 1 or more employers, any plan amendment 
made pursuant to a collective bargaining agreement relating to 
the plan which amends the plan solely to conform to any 
requirement added by this section shall not be treated as a 
termination of such collective bargaining agreement.
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