H.R. 5813: Women’s Health and Cancer Rights Modernization Act of 2025

This bill, named the Women’s Health and Cancer Rights Modernization Act of 2025, seeks to amend existing health care laws to require specific coverage for breast or chest wall reconstruction when it is part of breast cancer treatment. Here are the primary components of the bill:

Coverage Requirements

The bill mandates that group health plans and health insurance providers must cover the following related to reconstruction after breast cancer treatment:

• Medical Treatment: This includes surgery to remove diseased breast tissue, such as mastectomy and breast-conserving surgeries.
• Types of Reconstruction: Coverage must include all methods of breast reconstruction:
  • Implant-based reconstruction.
  • Tissue-based reconstruction.
  • Any new methods recognized in future medical coding systems.
• Types of Reconstruction Procedures: Each type of reconstruction must also be covered, including:
  • Immediate and delayed implant-based reconstruction.
  • Various tissue flap techniques.
  • Combined implant- and tissue-based methods.
• Full Spectrum of Reconstruction: All stages of breast or chest wall reconstruction must be covered, including procedures to achieve symmetry between both sides of the body where reconstruction takes place.
• Custom Prostheses: Custom-fabricated breast prostheses and any replacements must also be included in the coverage.
• Treatment of Complications: Any complications arising from mastectomy or reconstruction must be covered, including lymphedema compression treatments.

Manner of Coverage

Insurance coverage is to be provided in consultation with the patient's physician and the patient themselves, ensuring that it aligns with the patient's medical needs. Coverage may involve annual deductibles and coinsurance similar to other health benefits. Insurers are required to notify plan participants annually about the coverage available for these services.

Provider Access

The bill stipulates that health insurance plans must ensure that at least one in-network provider is available for each type of reconstruction covered. This aims to facilitate patient access to affordable care.

Notification Requirements

Health plans must provide clear written notice to individuals about their coverage options related to breast cancer reconstruction at enrollment and annually thereafter. This notification must be plainly visible in any material provided by the insurance plan.

Prohibitions on Discrimination

The bill prohibits group health plans from denying a patient's eligibility for coverage solely to circumvent these requirements. Additionally, insurance plans cannot penalize providers for delivering care in a manner consistent with this section.

Negotiation and Compliance

Although insurers must comply with these coverage requirements, they still retain the right to negotiate reimbursement levels with healthcare providers.

States' Rights

The provisions in this bill do not override state laws that mandate broader coverage for breast cancer care than what is required under federal law.

Reporting Requirement

The bill also requires that, within one year of enactment, the Comptroller General submits a report detailing any access barriers related to breast reconstruction services, which aims to identify gaps in available care.

Effective Date

The changes proposed in this bill would apply to plan years that begin on or after its enactment. Special provisions are made for collective bargaining agreements to ensure that any necessary changes to comply with the law do not terminate these agreements.

Relevant Companies

• MDLZ: Mondelez International may see an impact as they offer benefits to their employees and may need to adjust health insurance plans in alignment with this new requirement.
• UNH: UnitedHealth Group, a major health insurance provider, would be required to update policy offerings to comply with the new coverage mandates.
• ANTM: Anthem, another significant health insurance provider, may need to review and alter its services to comply with the reconstruction coverage requirements outlined in the bill.