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While many women experience smooth sailing with their requests for reconstruction,
for others it an be a frustrating, time-consuming battle.
The Women's
Health and Cancer Rights Act (WHCRA) is a federal law that requires group health plans to pay for
the following services after mastectomy:
•
Breast prosthesis
• Breast reconstruction
• Surgery to the other breast to achieve a symmetrical appearance
• Treatment for complications from mastectomy or reconstruction
Most states also have laws regarding reconstruction benefits, including those provided
by individual (rather than group) health policies. Legal exemptions
Two particular circumstances are exempt from the WHCRA mandate. The law doesn't
require insurers to pay for mastectomies, but if they do, they must also pay for reconstruction, even
if your mastectomy was paid for by a previous health insurance company.
Coverage is not retroactive:
if you weren't insured with your current plan before January 1999 or you had a mastectomy
before that time, your insurer is not obligated to cover your reconstruction.
What's
covered, what's not
If a health plan covers mastectomy and reconstruction,
it must do so under its overall guidelines. You pay the same deductibles and co-payments as you
do for other medical services. In other words, if your coverage normally pays 80 percent of medical services and you pay
the remaining 20 percent, the same payment ratio applies to your reconstruction-related expenses.
WHCRA mandates payment for reconstruction, but how much must be paid and to whom is left
up to the health plan.
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