Breast Reconstruction: Understanding the Women’s Health and Cancer Rights Act

By Dr. Constance M Chen

 A diagnosis of breast cancer profoundly impacts a woman's life. In addition to coping with overwhelming emotions, she must make important choices about treatment and all of its implications. One of those is the financial ramifications of her illness, particularly if she will need surgical treatment of her breast. She will need to learn all she can about her insurance coverage. Will the breast surgeon, the anesthesiologist, the hospital, the lab be covered? What about procedures on the healthy breast to ensure symmetry? And what if she elects to have breast reconstruction at a later date? Fortunately, all insurance companies in the United States are required to cover breast reconstruction if mastectomy - which includes partial mastectomy (i.e., lumpectomy) - is also covered, so any woman undergoing surgical treatment of her breasts should be aware of her rights.

In 1998, Congress passed the Women’s Health and Cancer Rights Act (WHCRA), a federal law that requires group health plans and individual health policies that cover mastectomy to also cover breast reconstruction in connection with mastectomy. Before the passage of the WHCRA, insurers could refuse coverage for reconstruction on the grounds that these were cosmetic procedures and not medically necessary. Women had to pay for reconstruction themselves or forgo it. Patients, survivors, healthcare workers, and their supporters worked hard to ensure that a woman would be legally guaranteed the option of reconstructive surgery following mastectomy.

The WHCRA has specific provisions for breast reconstruction in connection with mastectomy. Insurance benefits are required to include the following:

●        All stages of reconstruction of the breast on which the mastectomy or lumpectomy was performed;

●        Surgery and reconstruction of the other breast to achieve symmetry and balance;

●        Prostheses, if needed, and treatment of any complications of surgery, including lymphedema;

●        One home healthcare visit within 48 hours of hospital discharge;

●        Outpatient or inpatient care in a healthcare facility based on generally accepted criteria.

Under the WHCRA, women are legally entitled to the breast reconstruction method of their choice - even if the woman's chosen plastic surgeon is outside the insurer's network. And while it is important to remember that patients will be responsible for deductible and co-insurance payments as with any other care covered by their plans, it is also true that when insurance companies have denied claims or presented obstacles to coverage, challenging those decisions, up to the state's attorney general if necessary, can be successful with skilled patient advocates who fight for you.

The WHCRA is of enormous value to women. It provides a crucial baseline benefit in helping women recover from breast cancer. The sponsors of the WHCRA in Congress understood that breast reconstruction was often pivotal for a woman’s physical and emotional well-being. In my practice, we work hard to ensure that women can focus their energies on getting well without the additional burden of financial pressure, so we do everything we can to relieve our patients of the anxiety and stress of managing the relationship with their insurers.