Title: Breast Cancer Patient Equity Act
Policy area: Health

Summary:
Breast Cancer Patient Equity Act
This bill provides for Medicare coverage of custom fabricated breast prostheses following the surgical removal of the breast (i.e., a mastectomy), including replacements of such prostheses. Currently, Medicare covers surgically implanted breast prostheses, as well as some external breast prostheses (e.g., post-surgical bras).

[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 562 Introduced in Senate (IS)]

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116th CONGRESS
  1st Session
                                 S. 562

To amend title XVIII of the Social Security Act to provide coverage for 
      custom fabricated breast prostheses following a mastectomy.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           February 26, 2019

   Ms. Duckworth (for herself, Ms. Murkowski, Ms. Klobuchar, and Mr. 
Brown) introduced the following bill; which was read twice and referred 
                      to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to provide coverage for 
      custom fabricated breast prostheses following a mastectomy.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; FINDINGS.

    (a) Short Title.--This Act may be cited as the ``Breast Cancer 
Patient Equity Act''.
    (b) Findings.--Congress finds the following:
            (1) There are currently more than 3,500,000 women with a 
        history of breast cancer in the United States, many of whom 
        experience unreconstructed breast loss.
            (2) In 2018, more than 260,000 women were diagnosed with 
        invasive breast cancer that required surgery, with many having 
        to undergo surgical breast removal.
            (3) In 2018, more than 40,000 women in the United States 
        are expected to die from breast cancer.
            (4) Annually, there are 144,000 women in the United States 
        who undergo mastectomies, a surgical removal of the breast.
            (5) The number of breast mastectomies in the United States 
        has increased among younger women, ages 18 to 34 years old, at 
        a rate of 30 percent and at a rate of 15 percent for women ages 
        35 to 44 years old.
            (6) The results of breast reconstruction surgery can vary 
        and, as with any surgical procedure, there are inherent risks 
        associated with such surgery. Additionally, reconstruction of 
        the breast using implants requires lifelong follow up to ensure 
        the health of the patient.
            (7) While the number of women choosing to undergo surgical 
        breast reconstruction continues to increase, many women 
        continue to lack the viable option of custom fabricated 
        prosthetic breasts to restore the lost breast.
            (8) Both older women and minority women are less likely to 
        be offered or undergo surgical breast reconstruction and are 
        disproportionately disadvantaged by a lack of access to the 
        option of custom fabricated prosthetic breasts.
            (9) Currently, the Medicare program provides coverage and 
        reimbursement for custom fabricated prostheses for any body 
        part, with the exception of breasts, that has been lost.
            (10) Following passage of the Women's Health and Cancer 
        Rights Act of 1998 (Public Law 105-277; 42 U.S.C. 201 note), 
        many private insurers and group health plans began to provide 
        coverage for custom fabricated breast prostheses as an 
        alternative to surgical breast reconstruction.
            (11) While the Medicare program recognizes custom 
        fabricated breast prostheses as a discrete device and valid 
        treatment option, having assigned a billing code for such 
        option under the Healthcare Common Procedure Coding System 
        (``HCPCS'') and setting a maximum allowable fee, Medicare does 
        not provide reimbursement and denies claims as `not medically 
        necessary'. Medicare does provide reimbursement, however, for 
        more costly surgical breast reconstruction.
            (12) Due to the fact that the Medicare program does not 
        provide reimbursement for custom fabricated breast prostheses, 
        many private insurance companies have also begun to limit their 
        reimbursement for them.
            (13) The Department of Veterans Affairs does provide the 
        option of a custom fabricated prosthetic breast for women post-
        mastectomy.
            (14) Providing coverage for custom fabricated prosthetic 
        breast devices and components will not increase the incidence 
        of breast mastectomies.

SEC. 2. COVERAGE.

    (a) In General.--Section 1861(s)(8) of the Social Security Act (42 
U.S.C. 1395x(s)(8)) is amended--
            (1) by adding ``and'' after the semicolon at the end;
            (2) by inserting ``(A)'' after ``(8)''; and
            (3) by inserting after subparagraph (A) the following new 
        subparagraph:
            ``(B) custom fabricated breast prostheses following 
        surgical removal of the breast, including replacement of such 
        prostheses;''.
    (b) Conforming Amendment.--Section 1862(a)(7) of such Act (42 
U.S.C. 1395y(a)(7)) is amended by striking ``1861(s)(8)'' and inserting 
``1861(s)(8)(A)''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after the date of enactment 
of this Act.
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