Women’s Health and Cancer Rights Modernization Act of 2025

Bill Number

H.R. 5813

Origin Chamber

House

Congress

119th Congress, Session 1

Policy Area

Health

Status

Introduced

Latest Action

2025-10-24: 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.

Last Updated

2025-12-02T16:49:22Z

AI-Generated Summary

Purpose

The "Women's Health and Cancer Rights Modernization Act of 2025" (H.R. 5813) aims to expand and update federal requirements for health insurance coverage of breast cancer treatments, specifically focusing on breast or chest wall reconstruction. It builds on existing laws to ensure comprehensive access to these services for patients who elect reconstruction, reducing barriers to care and promoting equitable treatment options.

Key Provisions

• Required Coverage: Group health plans and health insurance issuers offering group or individual coverage must provide benefits for breast cancer treatment that includes:
• Removal or medical treatment of diseased breast tissue (e.g., mastectomy or breast-conserving surgery).
• All modalities of reconstruction, such as implant-based (using artificial inserts), tissue-based (using the patient's own tissue), and any future methods recognized in the Healthcare Common Procedure Coding System (HCPCS Level I, a standard medical billing code set).
• Specific types within modalities, including immediate/delayed implants, various flap techniques (e.g., myocutaneous or microvascular free flap), fat grafting, combined methods, and future developments added to HCPCS codes.
• All procedural variations noted in HCPCS descriptions.
• All stages of reconstruction on the affected breast or chest wall, including "flat closure" (no reconstruction).
• Surgery on the unaffected breast or chest wall for symmetry.
• Custom breast prostheses and their replacements.
• Treatment of complications from surgery, radiation, or lymph node procedures, including lymphedema compression items (swelling treatment devices; removes the current January 1, 2024, start date restriction under Medicare rules).
• Patient-Centered Delivery: Coverage must be provided in consultation with the patient's doctor and based on medical suitability. It can include standard deductibles (out-of-pocket costs before insurance pays) and coinsurance (percentage paid by the patient), matching other plan benefits. Written notice of coverage must be given at enrollment and annually.
• Network Access: Plans must ensure at least one in-network (covered without extra out-of-pocket costs) provider for every reconstruction modality, type, and variation.
• Notice and Disclosure: Insurers and plans must prominently notify enrollees about this coverage in writing upon enrollment and in annual packets, per regulations from the Secretary of Health and Human Services (HHS).
• Prohibitions: Plans cannot deny or limit enrollment/renewal to avoid these requirements, penalize providers (e.g., reduce payments), or incentivize substandard care that deviates from accepted medical standards.
• Flexibility and Preemption: Plans can negotiate payment rates with providers. The law does not override state laws that provide equal or stronger protections for breast cancer care coverage.
• Reporting Requirement: Within one year of enactment, the Government Accountability Office (GAO, an independent congressional watchdog) must report to Congress on gaps or barriers to breast reconstruction access, including advanced techniques like microsurgery.
• Effective Date: Applies to plan years starting on or after enactment. For plans under collective bargaining agreements (labor contracts), updates to comply are not considered contract terminations.

Significant Changes to Existing Law

This bill amends three major laws—the Public Health Service Act (PHSA, governing public health insurance standards), the Employee Retirement Income Security Act (ERISA, regulating employer-sponsored plans), and the Internal Revenue Code (IRC, for tax-qualified plans)—to modernize the 1998 Women's Health and Cancer Rights Act (WHCRA). Key updates include:

• Expanding coverage beyond basic post-mastectomy reconstruction to encompass chest wall procedures, all reconstruction types/modalities (including future innovations via HCPCS), flat closure options, and complication treatments like lymphedema without date limits.
• Adding mandatory in-network provider access, which was not explicitly required before.
• Strengthening notice, prohibition, and patient consultation rules for broader applicability.
• Updating section headers and tables of contents in ERISA and IRC for clarity, and conforming PHSA amendments to supersede prior notice exemptions for certain plan years.

Potential Impacts

• On Citizens: Breast cancer patients and survivors gain broader, more predictable access to reconstruction options, potentially improving physical and emotional recovery while reducing unexpected costs. This could benefit an estimated 300,000+ annual U.S. breast cancer diagnoses, especially those electing reconstruction (about 20-30% post-mastectomy).
• On Government Agencies: HHS, the Department of Labor (DOL, for ERISA enforcement), and the IRS must issue regulations for notices and compliance, increasing administrative workload. The GAO's report may inform future policy adjustments.
• On Health Insurers and Plans: Could raise premiums or costs due to expanded mandates and network requirements, but allows reimbursement negotiations to mitigate. Promotes standardization across plans.
• On International Relations: No direct impact, as this is a domestic health insurance regulation.

Main Stakeholders Affected

• Breast Cancer Patients and Beneficiaries: Primary beneficiaries, ensuring choice in reconstruction without coverage denials.
• Health Insurance Issuers and Group Health Plans: Must update policies, networks, and communications to comply, facing potential enforcement actions.
• Healthcare Providers: Surgeons and specialists (e.g., plastic/reconstructive surgeons) gain protected reimbursements and incentives for comprehensive care; must align with medical standards.
• Employers and Plan Sponsors: Responsible for ERISA/IRC-compliant plans, including notice delivery and network adequacy.
• Government Entities: HHS, DOL, IRS for oversight; Congress and GAO for reporting and evaluation.
• Advocacy Groups: Organizations focused on women's health and cancer rights may influence implementation.

Notable Legal, Constitutional, or Political Implications

• Legal: Reinforces federal mandates under the Affordable Care Act framework, potentially increasing litigation risks for non-compliant plans (e.g., denial of benefits suits). The preemption clause preserves state-level enhancements, avoiding conflicts with varying state insurance laws. References to HCPCS ensure adaptability to medical advancements without frequent legislative updates.
• Constitutional: Aligns with Congress's authority under the Commerce Clause to regulate interstate health insurance markets, similar to prior WHCRA upheld in courts.
• Political: Demonstrates bipartisan support (introduced by representatives from both parties), signaling broad consensus on women's health equity. Could set precedent for expanding coverage in other cancer or reconstructive care areas, influencing future health policy debates.

This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.

Sponsor

Rep. Cammack, Kat [R-FL-3]

Cosponsors (13)

Rep. Dingell, Debbie [D-MI-6], Rep. Hinson, Ashley [R-IA-2], Rep. McBath, Lucy [D-GA-6], Rep. Kim, Young [R-CA-40], Rep. McClain Delaney, April [D-MD-6], Rep. Van Duyne, Beth [R-TX-24], Rep. Perez, Marie Gluesenkamp [D-WA-3], Rep. Pettersen, Brittany [D-CO-7], Rep. Lee, Laurel M. [R-FL-15], Rep. Maloy, Celeste [R-UT-2], Rep. Stansbury, Melanie A. [D-NM-1], Rep. DesJarlais, Scott [R-TN-4], Rep. Frankel, Lois [D-FL-22]

Recent Actions

• 2025-10-24: 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.
• 2025-10-24: 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.
• 2025-10-24: 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.
• 2025-10-24: Introduced in House
• 2025-10-24: Introduced in House

Bill Versions

• Women’s Health and Cancer Rights Modernization Act of 2025 — issued 2025-10-24 — PDF (18 pages)