Insurance companies are required by federal law to cover breast reconstruction after a mastectomy, whether through private insurance or government plans like Medicare.
Based on your medical condition and preferences, post-mastectomy reconstruction surgery could take place immediately or months or years post-mastectomy. Your surgeon will help determine the ideal timing.
The Women’s Health and Cancer Rights Act of 1998 (WHCRA)
Since 1998, women who undergo mastectomy or other medical procedures to treat breast cancer have been guaranteed that reconstructive surgery would be covered by insurance thanks to the Women’s Health and Cancer Rights Act of 1998 (WHCRA). This federal law mandates most group health plans including HMOs, PPOs and private insurers cover reconstructive surgery when mastectomy results from being diagnosed with breast cancer.
WHCRA was passed by Congress and signed into law on October 21, 1998, having far-reaching effects.
People frequently wonder whether reconstruction surgery they want is covered by their health insurance. Doctors are currently facing changes in how they’re reimbursed for these procedures, which could make them less accessible to people covered by insurance plans – some of these changes stemming from conversations happening across health care nationwide.
One of the key ways we as individuals can influence health services is through increasing knowledge about how access and cost interact with individual needs. Furthermore, understanding our state and nation’s laws has an enormous effect on us all – this knowledge will lead to positive action that improves lives across both.
Reconstructive surgery after mastectomy is the only means of restoring its natural appearance; however, multiple surgeries may be necessary and should take place either simultaneously with or at some time after mastectomy. Breast reconstruction surgery has many variations that are used to accomplish its goals; depending on its complexity and frequency of occurrence.
The WHCRA applies only to certain group health plans and insurance companies; Medicare or Medicaid have their own regulations regarding breast reconstruction coverage, so women seeking information should contact those offices directly for more details about their coverage.
Women undergoing mastectomy who wish to undergo breast reconstruction should discuss costs and coverage with their doctors. Some opt to cover their surgery themselves out-of-pocket while others rely on insurance provider coverage; the Women’s Health & Cancer Rights Act does not prohibit insurance providers from imposing deductibles and coinsurance requirements in relation to reconstruction surgery as long as these rates match up with those used for other benefits associated with mastectomy surgery.
Medicare
Breast cancer patients facing mastectomy can find themselves devastated. Reconstructing to improve self-image may follow and many wonder whether their insurance provider will cover reconstruction procedures. Luckily, most group plans that offer coverage of both procedures – mastectomies and reconstructions – require insurers to cover both procedures under federal law.
Depending on her cancer treatments, chemotherapy or radiation, she may need to postpone breast reconstruction until after chemotherapy or radiation treatments have completed. Most doctors will not discourage it due to insurance coverage concerns.
Medicare typically covers surgeries that restore functionality to damaged body parts, including reconstructive ones like rhinoplasty (or nose job), blepharoplasty (eyelid surgery to eliminate droopy eyelid tissue) or panniculectomy, which removes excess skin and tissue in the lower belly area. However, Medicare typically doesn’t cover cosmetic surgeries like facelifts or breast augmentation.
Accessing breast reconstruction should be accessible for women living with breast cancer. They should discuss their options with support groups they belong to as well as healthcare providers early on; before beginning treatments.
If you are uncertain of your next steps, speaking honestly to your physician about what your needs are is the best way forward. He or she should be able to recommend an approach that matches them; some techniques require multiple surgeries over multiple months before giving a solution that meets them all.
Most women who undergo a mastectomy will experience some level of breast numbness and loss of sensation as nerves that provide sensation to their breasts are cut during surgery. However, plastic surgeons continue to develop techniques that allow them to spare and repair these nerves.
Undergoing breast reconstruction surgery can also be complicated by certain health conditions that hinder healing or increase risk, such as diabetes and circulatory issues, for which recovery time may be slower; heavy smokers are also at a higher risk of complications during and post surgery.
Medicaid
At times of breast cancer diagnosis, making the decision to undergo a mastectomy can be emotionally and financially strainsome for women. Luckily, federal law mandates health insurance providers cover reconstruction in certain situations – so if this procedure interests you, Dr. Oren Lerman’s staff can assist in helping you understand what your insurance coverage offers as well as provide advice about what steps to take next.
Under the Women’s Health Coverage and Responsibility Act (WHCRA), insurance companies cannot increase deductibles or co-payments to exclude breast reconstruction coverage, and must reimburse physicians at a similar rate as for other medical procedures. Furthermore, insurers may not offer inducements or inducements for surgeons not to perform surgery and cannot change eligibility requirements or deny coverage on certain conditions.
Women considering autologous breast reconstruction must understand that moving tissue from one part of their bodies to another may cause complications, including infection or poor circulation; additional surgeries may be required if such complications arise, although plastic surgeons have made great strides in providing more natural-looking results from this form of reconstruction than ever before.
Women undergoing implant-based reconstruction typically face one common complication known as capsular contracture. This condition occurs when scar tissue forms around implants and tightens them down over time, creating capsular contracture. If necessary, further surgery may be needed after healing from initial procedure has taken place.
As part of breast reconstruction, the Women’s Health and Cancer Rights Act of 2012 requires insurers to pay for physical therapy as an additional form of assistance during recovery. Physical therapy helps women adapt to their new body while finding ways to live safely and comfortably with it. Physical therapy also can restore range of motion in her shoulder as well as address weakness caused by having had donor tissue taken from elsewhere (for instance abdominal).
The CWCRA also requires health insurers to cover mastectomy-related costs, including any medically necessary hospital stays, for patients. This policy ensures their medical records remain private while protecting them against being used against them in future claims for new or ongoing illnesses by insurers.
Private Insurance
Many private health insurance policies now include breast reconstruction as a component of mastectomy coverage, due to requirements outlined by the Women’s Health and Cancer Rights Act. Specific details may differ slightly between states and insurers; however, their core principles remain universal.
Insurance providers may impose higher deductible or co-insurance costs for reconstructive procedures than they would for other surgeries, which isn’t illegal but can make reconstruction less affordable for some patients. Therefore, it is crucial that patients discuss their options with their doctors as well as look into financial assistance programs or any available resources that might assist.
Private insurers may also be unwilling to cover prophylactic surgeries that reduce an individual’s risk of cancer in the future, such as hysterectomy or salpingo-oophorectomy for individuals who carry hereditary mutations that increase their chance of cancer development in later years. Women must understand their options carefully and consult their doctor about which path they wish to take before making this decision.
Women undergoing double mastectomy frequently opt for immediate reconstruction at the same time, which can reduce surgery sessions and make recovery smoother. Unfortunately, immediate reconstruction also poses certain risks like increased infection risk or skin death, radiation damage to newly reconstructed breasts, etc. For these reasons it may be wiser to delay reconstruction until later and undergo another surgery at another date.
No matter when a woman chooses to have breast reconstruction surgery, she must follow up with physical therapy afterward. Physical therapy will help her adjust to new physical limitations, improve shoulder range of motion and address any weakness at the site where tissue was taken from the body. Furthermore, for patients undergoing autologous or implant-based reconstruction techniques physical therapy may help treat symptoms like lymphedema.