The Breast Reconstruction Guidebook

While many women experience smooth sailing with their requests for reconstruction, for others it an be an incredibly frustrating, time-consuming battle.

The Women's Health and Cancer Rights Act (WHCRA) is a federal law requiring 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

Reconstruction benefits of individual health policies (as opposed to group plans) are governed by state laws. Many states also have additional laws regarding reconstruction.

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 to the health plan.