Coverage of cancer diagnostic and laboratory tests

(a)

Medicare

(1)

Coverage

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended—(A)in subsection (s)(2)—(i)in subparagraph (JJ), by adding and at the end; and(ii)by adding at the end the following new subparagraph:

(KK)cancer diagnostic and laboratory tests (as defined in subsection (nnn)) furnished on or after the date that is 6 months after the date of the enactment of this subparagraph.

; and

(B)by adding at the end the following new subsection:

(nnn)

Cancer diagnostic and laboratory tests

(1)

In general

The term cancer diagnostic and laboratory tests means—(A)microarray analysis, DNA sequencing, RNA sequencing, whole-exome sequencing, and other forms of next-generation sequencing furnished and reported by a clinical laboratory (as defined in section 353(a) of the Public Health Service Act); and(B)explanation and interpretation of any analysis or sequencing described in subparagraph (A);

furnished to an individual diagnosed with cancer.

(2)

Frequency

When an individual test as described in paragraph (1) reports out the same genetic content, it may only be furnished with respect to an individual diagnosed with a cancer—(A)once upon the diagnosis of such cancer; (B)once upon any recurrence of such cancer; and(C)as necessary for purposes of planning treatment or monitoring the progression of such cancer or the response of such cancer to treatment.

(2)

Payment

Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended—(A)in subsection (a)(1)—(i)by striking and before (HH); and(ii)by inserting the following before the semicolon: , and (II) with respect to cancer diagnostic and laboratory tests (as defined in section 1861(nnn)), the amount paid shall be an amount equal to 80 percent (or 100 percent, in the case of such tests for which payment is made on an assignment-related basis) of the lesser of the actual charge for the test or the amount that would have been determined for such test under section 1834A had such test been a clinical diagnostic laboratory test;; and(B)in subsection (b)—(i)by striking , and (13) and inserting (13); and(ii)by striking 1861(n). and inserting section 1861(n), and (14) such deductible shall not apply with respect to cancer diagnostic and laboratory tests (as defined in section 1861(nnn)). (3)

Exclusion modification

Section 1862(a)(1) of the Social Security Act (42 U.S.C. 1395y(a)(1)) is amended—(A)in subparagraph (O), by striking and at the end;(B)in subparagraph (P), by striking the semicolon and inserting , and; and(C)by adding at the end the following new subparagraph:

(Q)in the case of cancer diagnostic and laboratory tests (as defined in section 1861(nnn)), which are performed more frequently than is covered under such section;

(b)

Medicaid

(1)

Inclusion as medical assistance

Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is amended—(A)in paragraph (31), by striking and at the end;(B)by redesignating paragraph (32) as paragraph (33); and(C)by inserting after paragraph (31) the following new paragraph:

(32)cancer diagnostic and laboratory tests (as defined in section 1861(nnn)); and

(2)

Mandatory coverage

Section 1902(a)(10)(A) of such Act is amended, in the matter preceding clause (i), by striking and (30) and inserting (30), and (32).(3)

Inclusion in benchmark coverage

Section 1937(b)(5) of such Act is amended by inserting before the period at the end the following: , and beginning January 1, 2027, coverage of cancer diagnostic and laboratory tests (as defined in section 1861(nnn)).(4)

Effective date

(A)

In general

The amendments made by this section shall apply with respect to items and services furnished on or after January 1, 2027.(B)

Exemption for State legislation

In the case of a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), or waiver of such plan, that the Secretary of Health and Human Services determines requires State legislation in order for the respective plan to meet any requirement imposed by amendments made by this section, the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session shall be considered to be a separate regular session of the State legislature.(c)

CHIP

Section 2103(c) of the Social Security Act (42 U.S.C. 1397cc(c)) is amended by adding at the end the following new paragraph:

(13)

Coverage of cancer diagnostic and laboratory tests

Regardless of the type of coverage elected by a State under subsection (a), beginning January 1, 2025 child health assistance provided under such coverage for targeted low-income children and, in the case that the State elects to provide pregnancy-related assistance under such coverage pursuant to section 2112, such pregnancy-related assistance for targeted low-income pregnant women (as defined in section 2112(d)), shall include coverage of cancer diagnostic and laboratory tests (as defined in section 1861(nnn)).