Mastectomy 101

Federal law, and the laws of many states, require insurers to cover breast reconstruction if the cost of a mastectomy is covered.

State laws: For a list of the state laws concerning covering the cost of reconstruction, see the American Society of Plastic Surgeons'  web site at www.plasticsurgery.org 

Federal Law: The Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires that health plans which cover a mastectomy must also cover:

• Reconstruction of the breast on which a mastectomy has been performed.
• Reconstruction on the other breast to produce a symmetrical appearance.
• Prostheses and physical complications at all stages of mastectomy, including lymphedemas.

This coverage can be subject to annual deductibles and co-insurance consistent with those established for other benefits under the plan or coverage. 

The plan must furnish a written description of this benefit upon enrollment in the plan and each year thereafter. According to the Department of Labor, the annual notice can be delivered anytime during a plan year. The notice may be separate or may be included in other communications.

WHCRA applies to all group and individual health plans, and their insurance companies or HMOs that provide coverage for medical and surgical benefits with respect to a mastectomy.

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