There are many factors to consider before having breast reconstruction, including cost and payment after surgery. Well, did you know that there are safeguards in place that allow you to have this procedure covered by your insurance?
A central reason that insurance companies are required to pay for breast reconstruction is the Women’s Health and Cancer Rights Act of 1998 (WHCRA). This federal law protects a woman’s right to have reconstruction after mastectomy due to medical reasons. This includes women who have had breast cancer, as well as those who have prophylactic mastectomies because of risk factors like a strong family history of breast cancer or gene mutations (e.g., BRCA1, BRCA2, PTEN, PALB2).
Generally, insurance companies must cover breast reconstruction if they also cover mastectomy. This applies to group health plans, individual insurance plans, and plans with Health Maintenance Organizations (HMOs). However, certain church or government plans are possible exceptions to this, so it’s important to check with your plan administrator about your mastectomy and reconstruction benefits if you have these kinds of insurance plans.
Beyond just initial reconstructive surgery, there are additional medical and surgical treatments for which insurance plans must provide benefits. These surgical benefits include all stages of reconstruction of the breast(s) removed during mastectomy, as well as surgery and reconstruction for the other natural breast for symmetry and appearance.
To protect women who wish to have breast reconstruction, insurance companies also can’t refuse or stop coverage to avoid WHCRA requirements and aren't allowed to penalize or incentivize physicians to keep them from providing care related to the WHCRA regulations.
To know the benefits and requirements you are entitled to after mastectomy, insurance companies must provide you with this information when you enroll in their plan and give you an annual notice detailing your mastectomy and reconstruction benefits.
What you do with your body after mastectomy should be your choice, and, thanks to the WHCRA, you have the right to receive breast reconstruction covered by your insurance. Contact your insurance company to learn more about the reconstruction benefits covered by your insurance plan, or contact our office to learn more about natural breast reconstruction and your coverage options.
