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Item/Service Description During recent years, there has been a considerable change in the treatment of diseases of the breast such as fibrocystic disease and cancer. While extirpation of the disease remains of primary importance, the quality of life following initial treatment is increasingly recognized as of great concern. The increased use of breast reconstruction procedures is due to several factors:
Indications and Limitations of Coverage Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a relatively safe and effective noncosmetic procedure. Accordingly, program payment may be made for breast reconstruction surgery following removal of a breast for any medical reason. Program payment may not be made for breast reconstruction for cosmetic reasons. (Cosmetic surgery is excluded from coverage under §l862(a)(l0) of the Act.) The Federal lawThe Women’s Health and Cancer Rights Act (WHCRA) helps protect many women with breast cancer who choose to have their breasts rebuilt (reconstructed) after a mastectomy. Mastectomy is surgery to remove all or part of the breast. This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law. There are additional protections under the Affordable Care Act (ACA). For plan years ( a plan year can be any 12-month period that the insurer chooses) beginning on or after January 1, 2014, a group health plan generally cannot limit or deny benefits relating to a pre-existing condition. The WHCRA:
Under the WHCRA, mastectomy benefits must cover:
Mastectomy benefits may have a yearly deductible and may require that you pay some out-of-pocket costs. Questions and answers about the WHCRADoes the WHCRA allow insurers to take people off their plans so that they don’t have to pay breast reconstruction benefits? No.The WHCRA does not allow insurance plans and insurance companies to kick people out of the plan or keep them from enrolling or renewing their coverage under the plan to avoid WHCRA requirements. Does the WHCRA let insurance plans give doctors incentives to discourage women from having breast reconstruction after mastectomy? No. The WHCRA does not allow insurance plans and insurance issuers to penalize doctors or lead them to provide care in a way that does not support the WHCRA. Nor does it allow insurance plans to reward doctors who do not encourage their patients to look into breast reconstruction. Does my insurance provider have to tell me that I’m covered for breast reconstruction under the WHRCA? Yes. The law also requires that insurance providers notify you of this coverage when you enroll in their plan, and every year after that. What if my state has laws that require insurers to cover breast reconstruction? Several states have their own laws requiring health plans that cover mastectomies to provide coverage for reconstructive surgery after a mastectomy. These state laws only apply to those health plans purchased by an employer from a commercial insurance company. If an employer is self-insured, state laws do not apply but federal laws do. A self-insured (or self-funded) plan is one in which the employer, rather than a commercial insurance company, pays for the insured person’s health expenses. Some employers that self-insure will hire a commercial insurance company to write the checks and track the paperwork, even though the money for the payments still comes from the employer. So it can be hard to tell whether you are in a self-insured or a commercially insured plan unless you ask. If you are unsure of your plan’s status, ask your employer’s benefits manager. I have been diagnosed with breast cancer and plan to have a mastectomy. How will the WHCRA affect my benefits? Under the WHCRA, group health plans, insurance companies, and HMOs that offer mastectomy coverage must also provide coverage for reconstructive surgery after mastectomy. This coverage includes reconstruction of the breast removed by mastectomy, reconstruction of the other breast to give a more balanced look, breast prostheses, and treatment of physical complications at all stages of the mastectomy, including lymphedema. This federal law sets a minimum requirement so that women can have breast reconstruction after mastectomy, even if they live in states that do not make insurance companies provide this coverage. Does the WHCRA require all group plans, insurance companies, and HMOs to provide reconstructive surgery benefits? In most cases, yes, as long as the insurance plan also covers medical and surgical benefits for mastectomies. But certain church plans and government plans may not be required to pay for reconstructive surgery. If you are insured under a health plan sponsored by a church or local government plan, check with your plan administrator about it. Under the WHCRA, can insurance providers impose deductibles or co-insurance requirements for reconstructive surgery in connection with a mastectomy? Yes. But the deductibles and co-insurance must be like those that are used for other benefits under the plan or coverage. The company can’t have you paying a higher deductible or co-pay for breast rebuilding than you would pay for other types of surgery. If I have a mastectomy and breast reconstruction, am I also entitled to the state and WHCRA required minimum hospital stay? It depends. If you have coverage through your employer and your employer is insured, you would be entitled to the minimum hospital stay required by the state law. If you have coverage through your employer but your coverage is not provided by an insurance company or HMO (that is, your employer “self-insures” your coverage), then state law does not apply. In that case, only the federal WHCRA applies and it does not require minimum hospital stays. To find out if your group health plan is insured or self-insured, contact your plan administrator. If you have coverage under a private health insurance policy (not through your employer), check with your State Insurance Commissioner’s office to learn if state law applies. Are health plans required to tell me about WHCRA benefits? Yes. Both health plans and health insurance issuers are required to tell you about WHCRA benefits. They must do this when you enroll and every year after that. The annual notice may be sent by itself or it may be included in almost any written communication by the plan or insurer, such as newsletters, annual reports, policy renewal letters, enrollment notices, and others. Enrollment notices may even be a phone number or web address from which to get more information about coverage. Does the WHCRA affect the amount that my health plan will pay my doctors? No. The WHCRA does not keep a plan or health insurance issuer from bargaining about amounts and types of payment with doctors. But the law does forbid insurance plans and issuers from penalizing doctors or providing incentives that would cause a doctor to give care that’s not consistent with WHCRA. Does the new health care law affect the WHCRA? No. The WHCRA was not changed by the Affordable Care Act and there are no provisions or regulations that affect it. Health insurance plans that offer mastectomy must continue to offer breast reconstruction. Do the WHCRA requirements apply to Medicare or Medicaid? No. The law does not apply to Medicare and Medicaid. Still, Medicare covers breast reconstruction if you had a mastectomy because of breast cancer. Medicaid coverage varies in each state, so you will have to get this information for your state. Where can I get more information about my rights under the WHCRA? If you have more questions or concerns, you can contact:
You may also want to check the Additional resources section. Can you have breast reconstruction at the same time as a mastectomy?Surgery to reconstruct the breasts can be done (or started) at the time of the mastectomy (which is called immediate reconstruction) or it can be done after the mastectomy incisions have healed and breast cancer therapy has been completed (which is called delayed reconstruction).
How long does it take to recover from mastectomy and breast reconstruction?Average recovery time after mastectomy and reconstruction is about 3-4 weeks, but may be up to 6-8 weeks. During that time, there may be restrictions against driving and activities that involve lifting or raising the arms up over the head.
How much is a double mastectomy and reconstruction?How Much Does a Double Mastectomy Cost? On MDsave, the cost of a Double Mastectomy ranges from $4,094 to $24,161. Those on high deductible health plans or without insurance can save when they buy their procedure upfront through MDsave.
Does NC Medicaid cover breast reconstruction after mastectomy?1. Breast reconstructive surgery of the affected breast and reduction, mastopexy, and/or augmentation of the contralateral breast are covered in association with the primary mastectomy procedure for the following conditions: A. Malignant neoplasm of the breast.
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Does medicaid pay for breast reconstruction after mastectomy
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