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Bill

S 5258

A bill to amend title XI of the Social Security Act to establish a payment model to reimburse providers for furnishing comprehensive breast cancer risk assessments and developing personalized screening and risk-reduction plans, and for other purposes.

119th Congress Introduced by Bill Cassidy and 1 co-sponsor

Medicare would pay for breast cancer risk assessments plus personalized screening and risk-reduction plans to tailor prevention and early detection for beneficiaries.

Introduced in Senate
0
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Bill Summary · S 5258

Summary of Bill: S.5258 (119th Congress)

Purpose and intent

  • S.5258 proposes amending title XI of the Social Security Act to establish a new payment model under Medicare that reimburses providers for:
    • Furnishing comprehensive breast cancer risk assessments to patients.
    • Developing personalized screening and risk-reduction plans based on those assessments.
  • The overarching goal is to improve early identification of breast cancer risk and tailor screening and prevention strategies to individual patients.

Key provisions and changes

  • Medicare payment model: Creates a new reimbursement framework under title XI of the Social Security Act specifically for breast cancer risk assessment and personalized care planning.
  • Comprehensive risk assessment: Requires providers to perform thorough evaluations of a patient’s risk factors for breast cancer. This likely includes family history, genetic risk, prior breast health history, and other relevant clinical data.
  • Personalized screening plans: Based on the risk assessment, providers must develop individualized screening recommendations and schedules (e.g., age to begin screening, frequency, and modality).
  • Risk-reduction plans: Development of tailored strategies to reduce risk, which could include lifestyle counseling, chemoprevention considerations (e.g., discussing medications to lower risk), or preventive interventions as appropriate.
  • Reimbursement scope: Establishes payment for the time and resources involved in risk assessment, planning, and documentation. The exact payment rates, coding, and documentation requirements would be defined in regulations or implementing guidance consistent with the bill.
  • Reporting and quality: Likely includes requirements for reporting, quality measures, or outcomes to ensure proper use of funds and to monitor effectiveness, though specific metrics are not detailed in the summary.

Who and what is affected

  • Beneficiaries: Medicare beneficiaries who undergo breast cancer risk assessments and receive personalized screening and risk-reduction plans.
  • Providers: Clinicians and health care organizations that perform risk assessments and create individualized care plans for beneficiaries, eligible for reimbursement under the new model.
  • Medicare program: Adds a dedicated payment pathway under title XI to support risk assessment and personalized planning related to breast cancer.

Procedural and timeline aspects

  • Introduction and referral: Introduced in the Senate and referred to the Committee on Finance (as of the 2026-08-05 action history).
  • Sponsors: Co-sponsors include Senator Lisa Murkowski and Senator Bill Cassidy, indicating bipartisan support.
  • Next steps (typical for this type of bill): Passage by the Senate, potential reconciliation or modification, and alignment with the House of Representatives before any potential enactment. Implementation would require rulemaking for payment codes, rates, and clinical criteria.

Potential impact and considerations

  • Access and equity: Could enhance preventive care for Medicare beneficiaries by enabling structured risk assessment and personalized planning, potentially leading to earlier detection and tailored prevention strategies.
  • Provider incentives: Financial reimbursement could encourage clinicians to invest time in risk assessment and personalized planning, influencing practice patterns within Medicare.
  • Administrative requirements: Successful implementation would depend on clear coding, documentation requirements, and alignment with existing Medicare payment policies.
  • Data and outcomes: Effective use would require robust data collection to monitor utilization, appropriateness of risk-based plans, and health outcomes.

Note: This summary reflects the bill’s stated purposes and provisions as described in the available action history. Detailed legislative language would specify exact payment amounts, coding, eligibility criteria, and implementation timelines.

Compiled from official sources — confirm details with the bill’s official record.

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