Breast Reconstruction: Your Choice

The Breast Reconstruction Guidebook
Reconstruction Basics
Direct-to-Implant Reconstruction
Tissue Flaps
Hereditary Cancer
Find a DIEP, GAP or TUG Surgeon
Information for Surgeons

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Health Insurance

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.

Note: The information on this site is provided for educational purposes only and should not be interpreted as medical advice.
© 2003-2013 Kathy Steligo