Breast reconstruction is the right of every woman who has undergone a mastectomy. What's more, the Women's Health and Cancer Rights Act of 1998 [WHCRA] requires breast reconstruction after mastectomy as an option for patients. Not everyone is aware of this, which is why LifeCell™ is committed to getting the word out there to every woman who may need this information.
Many women opt for breast reconstruction after mastectomy. Many more might if they were aware of the WHCRA and their rights regarding insurance coverage for this surgical procedure.
The following information is intended to shed light on this important subject. Because there are differences between insurance plans or policies and insurers, this section of the site will help provide you with basic information on your rights and insurance coverage for breast reconstruction after cancer and mastectomy.
We hope you find it helpful — and reassuring.
The Women's Health and Cancer Rights Act of 1998 (WHCRA)
Under the Women's Health and Cancer Rights Act of 1998 (WHCRA), health insurers and their various health plans offering mastectomy coverage must also provide coverage for certain services relating to the mastectomy as determined in consultation between you and your physician(s).
This required coverage for related services includes all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the opposite breast to produce a symmetrical appearance; and prostheses and treatment of any physical complications of the mastectomy, including lymphedema.
Nothing in the WHCRA law limits the rights to breast cancer patients. Therefore, reconstruction surgery may be covered by insurance, even if a mastectomy is performed for reasons other than cancer. However, if your insurance coverage is provided by a non-profit or government entity, please check and verify your benefits with your insurance plan or your benefits manager. Certain plans including non-profit or government plans may not be subject to this law.
If you have recently changed jobs and were receiving benefits related to your mastectomy under a plan provided by your last employer, your new employer's plan may be required to cover reconstructive surgery if that plan provides coverage for mastectomies.
In addition, your new employer's plan generally is required to cover other benefits specified under WHCRA. It does not matter that your mastectomy was not covered by your new employer's plan.
A health insurance plan may limit benefits relating to a health condition that was present before your enrollment date in your current employer's plan through preexisting condition exclusion. A Federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which preexisting condition exclusion may be applied.
Notice of Your Rights
Health insurance plans must provide a notice to all employees when they enroll in the plan describing the benefits required by the WHCRA, and their coverage. These benefits include coverage of all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of any physical complications of the mastectomy.
The enrollment notice also must state that for the covered employee or their family member who is receiving mastectomy–related benefits, coverage will be provided in a manner determined in consultation with the patient and their physician(s).
Finally, the enrollment notice must describe deductibles and coinsurance that will apply to the coverage specified under WHCRA. Deductibles and coinsurance may be imposed only if they are consistent with those established for other benefits under the plan or coverage.
Annual WHCRA Notice
Your annual notice should describe the coverage required under WHCRA and information on how to obtain a detailed description of the mastectomy-related benefits available under your plan.
Individual Health Insurance Policies
Health insurance companies are required to provide WHCRA benefits to group or employer plans as well as to individual policies. Individual health insurance policies typically fall under the jurisdiction of State Insurance Departments. Contact your State Insurance Department or the U.S. Department of Health and Human Services toll free at 1.877.267.2323 extension 61565, for further information.
Knowing Your Health Insurance Coverage
If you're interested in beginning your breast reconstruction journey, here are some tips to follow to determine your health insurance coverage:
- Write down questions you may have concerning your health insurance coverage, such as:
- Does my plan cover my mastectomy and breast reconstruction?
Are there specific surgeons and facilities I can go to for this procedure?
Do I have to notify my health insurer of any procedures I have before my surgeon provides them?
- Are there different benefits if my procedure is done on an inpatient or outpatient basis or if the procedure is done in my doctor's office?
- What will my out–of–pocket expenses be?
Do I have a deductible for these procedures?
Do I have to pay a portion or co–insurance for each procedure?
- What other services will be covered with breast reconstruction procedures?
What about physical therapy, home–care services, possible medication and surgical supplies?
- Call the Member Service telephone number on your health insurance Identification Card. You will have to provide them with some information like your ID number, Group Plan number, Name and Date of Birth. It's best to start this process as soon as you begin to consider your breast reconstruction options. When speaking with a Member Services Representative from your health plan, write down the name of the representative, date, time, phone number and details of your discussion.
- Ask for your benefit information in writing. In the event you have questions about your health plan coverage, you can go back to this information. The representative may provide you a website address. Be sure to verify the address.
- Share the information you receive from your health insurance provider with your surgeon. You may want to provide the office manager copies of any information you receive or download concerning your benefit coverage.
- Throughout this process, if additional questions arise about your benefits, continue to contact your insurer's Member Service Department for clarification.
Important: Every health insurance benefit plan offers different coverage for hospital care, mastectomy and reconstructive procedures and services. Be familiar with your rights and insurance benefits.
LifeCell™ cannot make any guarantees or promises with regards to patient benefit coverage or levels of reimbursement. The above information is provided for reference only. Please contact your health insurer directly to confirm your specific benefit coverage.