This bill requires suppliers to inform Medicare beneficiaries undergoing a medically necessary mastectomy that breast reconstruction surgery is covered before performing the procedure, or face non-payment for the mastectomy.
Maxine Waters
Representative
CA-43
The Medicare Breast Reconstruction Access and Information Act mandates that suppliers performing medically necessary mastectomies must inform patients about their Medicare coverage for post-mastectomy breast reconstruction. This information must be provided and documented in the patient's medical file before the surgery takes place. Failure to comply will result in Medicare withholding payment for the mastectomy procedure.
New Medicare Rule Ties Mastectomy Payment to Patient Information Disclosure, Starting Next Year
The newly introduced Medicare Breast Reconstruction Access and Information Act aims to ensure that patients undergoing a medically necessary mastectomy know their rights regarding reconstructive surgery. Starting one year after the bill becomes law, Medicare will not pay for a mastectomy unless the provider takes a specific, documented step first.
The Checkpoint Before Surgery
Here’s the deal: If you need a mastectomy covered by Medicare, the healthcare supplier performing the procedure must inform you, the patient, that breast reconstruction surgery is covered under Medicare (specifically citing national coverage determination 140.2). They also have to document this conversation in your medical file before the mastectomy takes place. This is a clear attempt to boost patient awareness, ensuring that no one misses out on information about reconstructive options due to lack of communication at the provider level.
What Happens If They Miss a Step?
This is where the policy gets teeth—and potentially creates friction. The bill explicitly states that if the supplier fails to provide this required information and documentation before the surgery, Medicare will not pay for the mastectomy itself. Think of it as a mandatory administrative checkpoint. For patients, this is a clear win for informed consent, guaranteeing they hear about all their options before the primary surgery. For providers, however, it introduces a significant financial risk. If a busy hospital or surgical center misses the documentation step, they could lose Medicare payment for a medically necessary surgery, which could be a huge financial hit.
The Real-World Trade-Off
This law creates a classic policy trade-off: improved patient access versus increased administrative burden. On the one hand, it guarantees that every Medicare patient facing a mastectomy will be proactively informed about their right to reconstruction. This is a huge benefit, especially for patients who might be overwhelmed or unaware of the full scope of their coverage. On the other hand, the penalty for non-compliance—withholding payment for the primary, medically necessary mastectomy—is severe. This could create pressure on providers to prioritize paperwork over patient flow, or worse, lead to payment disputes that could indirectly impact patient care or facility finances down the line. It’s a powerful incentive for providers to comply, but it also raises the stakes significantly for what is essentially a documentation error.