The Access to Breast Cancer Diagnosis Act of 2025 adds a new federal requirement that group health plans and individual and group health insurance issuers may not impose any cost-sharing — including deductibles, coinsurance, copayments or limits on applying such cost-sharing — for medically necessary diagnostic and supplemental breast examinations. The bill defines those examinations by reference to National Comprehensive Cancer Network (NCCN) guidance and enumerates common technologies such as diagnostic mammography, breast MRI, and ultrasound.
Beyond the coverage mandate, the bill preserves standard utilization controls such as prior authorization, protects stronger state laws, amends the Affordable Care Act to bring grandfathered plans into scope, and adds an Internal Revenue Code safe harbor so high-deductible health plans remain HSA-eligible. The provisions take effect for plan years beginning on or after January 1, 2026 — creating discrete operational and compliance steps for carriers, plan sponsors, and administrators over the near term.
At a Glance
What It Does
The bill inserts a new Section 2730 into title XXVII of the Public Health Service Act that forbids cost-sharing for diagnostic and supplemental breast examinations when plans cover those services. It also amends the ACA to apply the rule to grandfathered plans and changes the tax code so HDHPs without a deductible for these exams still qualify for HSA eligibility.
Who It Affects
Health insurance issuers (individual and group markets), employer-sponsored group health plans (including self-insured ERISA plans), HSA-qualified high-deductible health plans, third-party administrators, and state insurance regulators. The rule also affects clinicians and imaging providers who bill and document diagnostic and supplemental breast exams.
Why It Matters
This is a narrowly targeted federal benefit mandate that removes a common financial barrier to follow-up breast imaging. Compliance will require changes to plan design, claims edits, coding guidance, and prior-authorization workflows, and may shift costs into premiums or utilization management tools.
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What This Bill Actually Does
The bill creates a single new federal requirement: when a plan already covers diagnostic or supplemental breast examinations, the plan cannot collect any patient cost-sharing for those services. It accomplishes this by adding Section 2730 to title XXVII of the Public Health Service Act and by defining key terms (cost-sharing, diagnostic breast examination, supplemental breast examination) in the statute rather than leaving them to regulation.
Rather than invent clinical criteria, the bill anchors clinical appropriateness to existing National Comprehensive Cancer Network (NCCN) guidance; that means insurers and reviewers will reference those clinical pathways when evaluating whether an exam is “medically necessary and appropriate.” The statutory definition explicitly lists diagnostic mammography, breast MRI, and breast ultrasound as examples, and the supplemental category covers risk‑based screening (for example, imaging recommended because of dense breasts, family history, or other risk factors).The bill does not eliminate utilization management. It expressly permits timely prior authorization and other “appropriate utilization controls,” which keeps clinical review tools available to plans while removing direct patient cost barriers at point of service.
It also includes a non‑preemption clause preserving any State law that already provides greater coverage protections.On the technical side, the text amends the ACA’s grandfathered-plan carve-out so a plan that otherwise qualifies as grandfathered must comply with the new Section 2730. It also adds a safe harbor to Internal Revenue Code section 223 so a high-deductible health plan will not lose HSA status if it waives the deductible for these breast imaging services.
The effective trigger is plan years that begin January 1, 2026 or later, which requires operational rollouts during 2025 for calendar-year plans.
The Five Things You Need to Know
The statutory ban on cost-sharing explicitly covers deductibles, coinsurance, copayments and any maximum limitation on applying those amounts — meaning plans cannot route the cost through aggregate out‑of‑pocket constructs for these exams.
Both diagnostic and supplemental breast examinations are tied to NCCN ‘medically necessary and appropriate’ criteria — the bill relies on that external clinical standard rather than prescribing adjudication rules in statute.
The statute preserves the right of plans and issuers to require prior authorization or other utilization controls — so clinical review can remain a gatekeeper even though patient cost-sharing is prohibited.
The bill amends the Affordable Care Act to bring grandfathered plans under the new requirement (it adds a specific clause to section 1251(a)(4)(A)), removing a common escape route for older employer plans.
Congress adds an Internal Revenue Code safe harbor so high-deductible health plans will not forfeit HSA eligibility solely because they exclude a deductible for these breast imaging services; the change applies to plan years beginning on or after January 1, 2026.
Section-by-Section Breakdown
Every bill we cover gets an analysis of its key sections.
Short title
A one-line provision: the measure is captioned the 'Access to Breast Cancer Diagnosis Act of 2025.' This has no legal effect beyond naming, but it signals the bill's targeted policy goal — improving access to diagnostic follow-up for breast cancer screening.
No patient cost‑sharing for covered diagnostic and supplemental breast exams
This is the operative command: when a plan provides benefits for diagnostic or supplemental breast examinations, the plan or issuer may not impose any cost-sharing requirements for those benefits. The drafting places the rule inside title XXVII, the ACA's coverage mandates framework, so it operates alongside other federal benefit rules.
Permitted utilization controls and state law savings clause
The bill explicitly states two limitations: plans may still use timely prior authorization and other utilization controls, and any state law that offers greater consumer protection remains in force. Practically, that means plans will need to preserve prior‑auth systems and coordinate with state regulators in jurisdictions that already require free follow-up imaging or broader protections.
Statutory definitions tied to NCCN and specific imaging modalities
The statute defines 'cost-sharing requirements' and provides statutory definitions for 'diagnostic breast examination' and 'supplemental breast examinations,' referencing NCCN standards and listing diagnostic mammography, breast MRI, and ultrasound as examples. Relying on NCCN makes clinical adjudication dependent on an externally maintained guideline rather than future federal regulation.
Brings grandfathered plans into coverage requirement
The bill amends section 1251(a)(4)(A) of the ACA to add the new Section 2730 to the list of requirements that affect the grandfathered plan exception. That change reduces the number of employer plans that could avoid the no‑cost‑sharing rule by claiming grandfathered status.
HSA safe harbor for absence of deductible
The bill appends a safe harbor to IRC section 223(c)(2) stating that failing to have a deductible for diagnostic and supplemental breast exams will not disqualify a plan from being an HSA‑compatible high-deductible health plan for plan years beginning on or after January 1, 2026. This is a technical but essential fix to keep HSA access intact while implementing the coverage change.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Women and people with breasts needing follow-up imaging: Eliminating point-of-care cost-sharing removes a direct financial hurdle to obtaining diagnostic mammography, breast MRI, or ultrasound after an abnormal screening or because of elevated risk.
- High‑risk individuals (dense breasts, family history): The supplemental exam definition covers risk‑based screening that these groups rely on, making additional imaging financially accessible and likely increasing detection opportunities.
- Imaging providers and specialists: Reduced patient refusal and fewer unpaid patient balances should improve downstream revenue realization and timeliness of diagnostic workups.
- Public health programs focused on early detection: Earlier diagnostic resolution can reduce late-stage treatment costs and improve population outcomes, helping screening programs meet quality and follow-up metrics.
Who Bears the Cost
- Health insurance issuers and plan sponsors (including self-insured employers): They must absorb or reallocate the costs previously borne by patients, which can raise premiums, employer contributions, or internal healthcare budgets.
- Third‑party administrators and payers' claims operations: Plans will need to change claims edits, eligibility rules, and benefit tables to exempt these services from patient cost-sharing, creating compliance and IT workload.
- HSA holders indirectly: While the HSA safe harbor preserves account eligibility, members may see premium increases or shifts in plan design that affect disposable income and contribution behavior.
- State insurance departments and compliance teams: Regulators and carrier compliance shops must interpret NCCN reliance, apply the state-law savings clause, and audit plan changes, increasing administrative oversight costs.
Key Issues
The Core Tension
The central dilemma is between removing financial barriers to timely diagnostic breast care (which supports earlier detection) and preserving plan tools to control utilization and overall costs: the bill eliminates out‑of‑pocket barriers but keeps utilization review, which may substitute administrative gates for financial ones and shift costs into premiums rather than reducing total system spending.
The bill balances a patient‑facing cost elimination with continued plan control over clinical appropriateness, but that compromise creates practical frictions. Relying on NCCN guidance externalizes clinical standards, which helps avoid micromanaging care in statute but also leaves ambiguity about which version of the guideline governs and how often plans may update criteria.
Disputes between providers, plans, and patients about whether a given exam meets the NCCN standard could increase appeals and utilization management disputes.
Allowing prior authorization while eliminating cost-sharing may blunt the law’s intended access gains if plans use authorization to delay or deny exams. Operationally, payers must retool coding and claim edits to ensure that exams identified as diagnostic or supplemental bypass copay and deductible logic — a nontrivial IT and compliance lift across product lines and billing systems.
Finally, while the IRC safe harbor preserves HSA status, shifting costs into premiums disperses the financial burden across all enrollees and employers rather than concentrating it at the point of care, raising equity and affordability questions that the statute does not address.
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