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.
Updated November 2011
