You may already know that federal law ensures your right to breast reconstruction. What you may not know is that the law does not guarantee any type of reconstruction performed by any plastic surgeon in any location.
The Women’s Health and Cancer Rights Act (WHCRA) was passed in 1998. For the first time, it required employer and union group health plans that pay for mastectomy (most do) to also cover the cost of breast prostheses and breast reconstruction. The law also applies to individual plans. (Employer group plans are regulated by the federal government; individual plans are governed by each state.) Prior to this law, 84% of plastic surgeons reported having patients who were denied coverage for breast reconstruction. Health insurance carriers often denied breast reconstruction after mastectomy, labeling it as “cosmetic surgery.”
Here’s a summary of what WHCRA does and does not stipulate, and what it means for health insurers and patients:
- According to the law, health plans that cover breast reconstruction must provide a description of WHCRA benefits to all employees when they enroll in the plan.
- If your health care policy covers mastectomy, it must also cover the cost of breast breast reconstruction. Certain “church plans” and “government plans” are not subject to the law.
- Plans must cover the cost of both breast prostheses and reconstruction. So if you decide to forego reconstruction at the time of your mastectomy and use prostheses instead, your plan must pay for the breast forms. If you then decide to have breast reconstruction at some later time, your plan must provide payment for that procedure.
- Coverage includes payment for all stages of breast reconstruction. If you have unilateral breast reconstruction, this includes surgical procedures (breast augmentation, lift or reduction) on the opposite healthy breast to achieve symmetry.
- Plans must also cover the cost of treating physical complications, including lymphedema, which may develop as a result of mastectomy.
- Your payment for reconstruction is limited to deductibles and coinsurance that are consistent with what you pay for other benefits under your healthcare plan.
- WHCRA allows policies to fulfill these requirements within the tenets of its existing health care policies. That means if your policy requires you to use in-network physicians and hospitals, it may deny approval and payment for reconstruction involving surgeons or medical facilities outside that network. It may also deny certain reconstructive procedures that are not performed by its in-network surgeons. This is a part of the law that is seldom explained, and women are often shocked to find that their HMO will not pay for reconstruction by an out-of-network surgeon who is in another state or across the country.
Visit the Department of Labor’s website (www.dol.gov/ebsa/publications/whcra.html) to access the text of the law and review a set of Q & A.