New Bill Targets Zero Out-of-Pocket for Key Breast Exams by 2026

A new piece of legislation, the 'Access to Breast Cancer Diagnosis Act of 2025,' is on the table, and it’s looking to shake up how certain breast exams are covered by your health insurance. The main idea, as outlined in SEC. 2, is that starting with plan years on or after January 1, 2026, this bill would require most group health plans and individual health insurance to cover diagnostic and supplemental breast examinations without hitting you with deductibles, coinsurance, or copayments. Essentially, it aims to remove those upfront costs when your doctor says you need a closer look after a screening or if you're at higher risk due to family history or other factors.

What "No Co-Pay" Really Means for Your Breast Health

So, what kind of exams are we talking about? The bill defines two types. A "diagnostic breast examination" is what you'd get if an initial screening (like a mammogram) shows something unusual, or if you or your doctor find a lump or other symptom that needs investigation. It's a medically necessary follow-up. Then there's a "supplemental breast examination," which is also medically necessary but used for screening individuals who don't have a suspected abnormality but might have a higher risk profile – think dense breast tissue, a strong family history of breast cancer, or other factors that your doctor deems relevant. For both these types of crucial exams, the bill says your insurance would have to cover them without you paying anything out-of-pocket first, starting in 2026. This could mean significant savings if you're facing these tests, which can often run into hundreds or even thousands of dollars depending on your plan's deductible.

The Catch: Navigating Insurance Green Lights

Now, here’s the part where you need to pay attention to the fine print, also in SEC. 2. While the bill aims to eliminate cost-sharing, it explicitly allows health plans to still require prior authorization and use other utilization controls for these diagnostic and supplemental exams. What does that mean for you? Your doctor might still need to get the insurance company’s okay before you can get the exam. Insurers use these tools to manage costs and ensure care is medically necessary, but it can sometimes lead to delays in getting appointments or even denials if the paperwork isn't just right. So, while the exam itself might not cost you, navigating the approval process could still be a hurdle.

Rewriting the Rules: How This Impacts Your Health Plan (and Maybe Your Taxes)

This isn't just a standalone rule; it’s designed to plug into the existing healthcare framework. The bill amends the Patient Protection and Affordable Care Act (specifically section 1251(a)(4)(A) and adding a new section 2730) to ensure these coverage requirements are integrated. More interestingly for folks with High Deductible Health Plans (HDHPs) often paired with Health Savings Accounts (HSAs), SEC. 2 also tweaks the Internal Revenue Code of 1986 (section 223(c)(2)). It creates a 'safe harbor' so that your HDHP can cover these breast exams before you’ve met your deductible, without jeopardizing the plan's status as an HDHP or your ability to contribute to your HSA. This is a pretty big deal because normally, HDHPs can only cover preventive services pre-deductible. This change would add these specific breast exams to that list for plan years starting on or after January 1, 2026, making it easier to access these diagnostic services without a big upfront cost, even if you have an HDHP.