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:

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

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:

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

(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.