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Health Insurance and Breast Reconstruction: What is Covered?

Does health insurance cover breast reconstruction? It’s not a simple yes or no question, as breast reconstruction coverage can be relatively complicated and depends on the circumstances surrounding the reconstruction.

The laws and regulations cover specific breast reconstruction surgery costs pertaining to medical purposes, the most notable being mastectomies, which are designed to remove breasts containing cancerous cells. With that said, some of the expenditures cover costs outside of just the initial mastectomy surgery. 

Here is some important information regarding health insurance coverage for breast reconstruction procedures:

Breast Reconstruction Coverage and the WHCRA

Those who want to understand whether or not insurance covers breast reconstruction must familiarize themselves with the Women’s Health and Cancer Rights Act, or WHCRA. Enacted in 1998, the WHCRA was designed to help people pay for breast reconstruction coverage. The act accomplishes this by requiring both group health plans and individual policies that cover mastectomy to also cover the costs for breast reconstruction. Some of the costs that women are entitled to include the following:

  • Reconstruction in the area where the mastectomy was performed is covered by the Women’s Health and Cancer Rights Act.
  • If breast reconstruction surgery is performed in another breast to help the person look symmetrical after their mastectomy, then it is also covered by the WHCRA.
  • All physical stages of the mastectomy are covered, including lymphedema.
  • Cancer patients who receive breast implant surgery following the removal of their cancerous breast also obtain coverage for the procedure.
  • Whether the reconstruction of the breast occurs shortly after the mastectomy procedure or several years later, insurance companies must cover the costs regardless of the timespan.

State Laws Regarding Insurance for Breast Reconstruction

Outside of the regulations of the Women’s Health and Cancer Rights Act, there are state laws that provide insurance for surgical procedures following a mastectomy. However, while all states in the United States have insurance coverage laws for breast reconstruction, they differ in wording and how much they cover.

For example, the insurance for breast reconstruction in New Jersey covers the surgery itself, procedures to obtain symmetry, and prostheses costs. Pennsylvania offers very similar insurance guidelines, but with the distinction that surgery on the opposite breast intended to restore symmetry must be performed within six years of the mastectomy; otherwise, the state will deny coverage. 

Some states specify how many prosthetics can be covered, with Nevada only covering two, while other places handle all breast reconstruction coverage. Before you get breast surgery, check the state laws of where you live to know what is and isn’t covered.

Medicaid and Breast Reconstruction Coverage

You might be wondering if the Women’s Health and Cancer Rights Act includes Medicaid, the program that offers health insurance coverage to American families that have low incomes. While the WHCRA does not include Medicaid, those who partake in the program can choose if they want insurance for breast reconstruction as a covered benefit in their plan.

If you ever need surgery for breast reconstruction or are considering breast reconstruction in Paramus, NJ, reach out to Art Plastic Surgery today!