Will health insurance pay for breast reconstruction?

Will health insurance pay for breast reconstruction?

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that requires group health plans and health insurance companies that offer mastectomy coverage to also pay for reconstructive surgery after mastectomy. This coverage must include all stages of reconstruction and surgery to achieve symmetry between the breasts, breast prostheses, and treatment of complications that result from the mastectomy, including lymphedema. More information about WHCRA is available from the Department of Labor and the Centers for Medicare & Medicaid Services.

Some health plans sponsored by religious organizations and some government health plans may be exempt from WHCRA. Also, WHCRA does not apply to Medicare or Medicaid. However, Medicare may cover breast reconstruction surgery as well as external breast prostheses (including a post-surgical bra) after a medically necessary mastectomy. Medicaid benefits vary by state; a woman should contact her state Medicaid office for information on whether, and to what extent, breast reconstruction is covered.

A woman considering breast reconstruction may want to discuss costs and health insurance coverage with her doctor and insurance company before choosing to have the surgery. Some insurance companies require a second opinion before they will agree to pay for a surgery.