Breast Cancer Patient Equity Act

II 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 fol- lowing a mastectomy. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE; FINDINGS. 3 (a) SHORT TITLE.—This Act may be cited as the 4 ‘‘Breast Cancer Patient Equity Act’’. 5 (b) FINDINGS.—Congress finds the following: 6 (1) There are currently more than 3,500,000 7 women with a history of breast cancer in the United 8 VerDate Sep 11 2014 22:57 Mar 01, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S562.IS S562 kjohnson on DSK79L0C42 with BILLS 2 •S 562 IS States, many of whom experience unreconstructed 1 breast loss. 2 (2) In 2018, more than 260,000 women were 3 diagnosed with invasive breast cancer that required 4 surgery, with many having to undergo surgical 5 breast removal. 6 (3) In 2018, more than 40,000 women in the 7 United States are expected to die from breast can- 8 cer. 9 (4) Annually, there are 144,000 women in the 10 United States who undergo mastectomies, a surgical 11 removal of the breast. 12 (5) The number of breast mastectomies in the 13 United States has increased among younger women, 14 ages 18 to 34 years old, at a rate of 30 percent and 15 at a rate of 15 percent for women ages 35 to 44 16 years old. 17 (6) The results of breast reconstruction surgery 18 can vary and, as with any surgical procedure, there 19 are inherent risks associated with such surgery. Ad- 20 ditionally, reconstruction of the breast using im- 21 plants requires lifelong follow up to ensure the 22 health of the patient. 23 (7) While the number of women choosing to un- 24 dergo surgical breast reconstruction continues to in- 25 VerDate Sep 11 2014 22:57 Mar 01, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S562.IS S562 kjohnson on DSK79L0C42 with BILLS 3 •S 562 IS crease, many women continue to lack the viable op- 1 tion of custom fabricated prosthetic breasts to re- 2 store the lost breast. 3 (8) Both older women and minority women are 4 less likely to be offered or undergo surgical breast 5 reconstruction and are disproportionately disadvan- 6 taged by a lack of access to the option of custom 7 fabricated prosthetic breasts. 8 (9) Currently, the Medicare program provides 9 coverage and reimbursement for custom fabricated 10 prostheses for any body part, with the exception of 11 breasts, that has been lost. 12 (10) Following passage of the Women’s Health 13 and Cancer Rights Act of 1998 (Public Law 105– 14 277; 42 U.S.C. 201 note), many private insurers 15 and group health plans began to provide coverage 16 for custom fabricated breast prostheses as an alter- 17 native to surgical breast reconstruction. 18 (11) While the Medicare program recognizes 19 custom fabricated breast prostheses as a discrete de- 20 vice and valid treatment option, having assigned a 21 billing code for such option under the Healthcare 22 Common Procedure Coding System (‘‘HCPCS’’) and 23 setting a maximum allowable fee, Medicare does not 24 provide reimbursement and denies claims as ‘not 25 VerDate Sep 11 2014 22:57 Mar 01, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S562.IS S562 kjohnson on DSK79L0C42 with BILLS 4 •S 562 IS medically necessary’. Medicare does provide reim- 1 bursement, however, for more costly surgical breast 2 reconstruction. 3 (12) Due to the fact that the Medicare program 4 does not provide reimbursement for custom fab- 5 ricated breast prostheses, many private insurance 6 companies have also begun to limit their reimburse- 7 ment for them. 8 (13) The Department of Veterans Affairs does 9 provide the option of a custom fabricated prosthetic 10 breast for women post-mastectomy. 11 (14) Providing coverage for custom fabricated 12 prosthetic breast devices and components will not in- 13 crease the incidence of breast mastectomies. 14 SEC. 2. COVERAGE. 15 (a) IN GENERAL.—Section 1861(s)(8) of the Social 16 Security Act (42 U.S.C. 1395x(s)(8)) is amended— 17 (1) by adding ‘‘and’’ after the semicolon at the 18 end; 19 (2) by inserting ‘‘(A)’’ after ‘‘(8)’’; and 20 (3) by inserting after subparagraph (A) the fol- 21 lowing new subparagraph: 22 ‘‘(B) custom fabricated breast prostheses fol- 23 lowing surgical removal of the breast, including re- 24 placement of such prostheses;’’. 25 VerDate Sep 11 2014 22:57 Mar 01, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S562.IS S562 kjohnson on DSK79L0C42 with BILLS 5 •S 562 IS (b) CONFORMING AMENDMENT.—Section 1862(a)(7) 1 of such Act (42 U.S.C. 1395y(a)(7)) is amended by strik- 2 ing ‘‘1861(s)(8)’’ and inserting ‘‘1861(s)(8)(A)’’. 3 (c) EFFECTIVE DATE.—The amendments made by 4 this section shall apply to items and services furnished on 5 or after the date of enactment of this Act. 6 Æ VerDate Sep 11 2014 22:57 Mar 01, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6301 E:\BILLS\S562.IS S562 kjohnson on DSK79L0C42 with BILLS