MUSC Advanced Breast Reconstruction program

Breast Reconstruction Law of 1998

Federal laws have been put in place to provide women who have health insurance the right to their preferred method of breast reconstruction – specifically the Women’s Health and Cancer Rights Act (WHCRA) of 1998, which is sometimes referred to as the 1998 Federal Breast Reconstruction Law.

In most cases, if your insurance plan provides coverage for the cost of a mastectomy, it also must provide coverage for your preferred method of breast reconstruction. This coverage includes reconstruction with perforator flaps, such as a DIEP flap. It applies to reconstruction at the same time as a mastectomy and to reconstruction done at a later date. It also includes surgery on the opposite breast to produce a symmetrical appearance (reduction, lift, augmentation) and treatment of physical complications including lymphedema.

If a surgeon in your provider network does not offer the method of reconstruction that you desire, your insurer still must provide coverage even though you may need to have surgery with a non-participating physician.

The U.S. Department of Labor provides the following fact sheet:

Women's Health and Cancer Rights Act

The Women's Health and Cancer Rights Act (WHCRA), signed into law on October 21, 1998, contains protections for patients who elect breast reconstruction in connection with a mastectomy. For plan participants and beneficiaries receiving benefits in connection with a mastectomy, plans offering coverage for a mastectomy must also cover reconstructive surgery and other benefits related to a mastectomy.

WHCRA:

  • applies to group health plans for plan years starting on or after October 21, 1998
  • applies to group health plans, health insurance companies or HMOs, if the plan or coverage provides medical and surgical benefits with respect to a mastectomy
  • requires coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient

Under WHCRA, mastectomy benefits must include coverage for:

  • reconstruction of the breast on which the mastectomy was performed
  • surgery and reconstruction of the other breast to produce a symmetrical appearance
  • prostheses and physical complications at all stages of mastectomy, including lymphedema

Under WHCRA, mastectomy benefits may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage.

The law also contains prohibitions against:

  • plans and issuers denying patients eligibility or continued eligibility to enroll or renew coverage under the
  • plan to avoid the requirements of WHCRA
  • plans and issuers providing incentives to, or penalizing, physicians to induce them to provide care in a manner inconsistent with the WHCRA

Group health plans, health insurance companies and HMOs covered by the law must notify individuals of the coverage required by WHCRA upon enrollment and annually thereafter.

 
 
 

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