Is Breast Reconstruction Covered By Insurance?

When you have breast cancer, your first concern is doing whatever is necessary to survive the disease. This can include the removal of one or both of your breasts.

Some women are fine with having no breasts after surgery while others want to undergo reconstructive surgery as soon as possible. There is no right or wrong answer, only what feels like the best decision for you.

One thing that can make a difficult decision even more challenging is concerns about whether insurance will cover the cost of breast reconstruction surgery. The federal government mandates that your insurance provider pay for the costs under certain circumstances. The Cecil B. Highland, Jr. and Barbara B. Highland Cancer Center at UHC encourage you to learn whether this applies to your current situation.

Federal Regulations Concerning Breast Reconstruction Surgery

The Women’s Health and Cancer Rights Act (WHCRA) was introduced by the Department of Labor and Health and Human Services in 1998 and passed by Congress the same year. Insurers that offer benefits for reconstructive surgery after a mastectomy must follow the mandates of WHRCA if the plan went into effect after October 1, 1998. This includes group health plans, health maintenance organizations (HMO), preferred provider organizations (PPO), and private insurers.

WHCRA also describes what insurance companies that offer benefits for a mastectomy must cover. This includes:

  • Breast implants
  • Breast reconstruction if it was removed to prevent the spread of cancer
  • Reconstructive surgery of the intact breast to create a symmetrical appearance
  • Treatment to address mastectomy complications, if any

If an insurance plan requires payment of a deductible or a percentage of the expenses for breast reconstructive surgery, it cannot be higher than it would be for other surgical procedures. Additionally, an insurer cannot change its eligibility requirements to deny coverage for surgery, offer incentives to surgeons to refuse the surgery, or pay a provider less for completing the surgery. Any of these actions could result in fines and other sanctions from the federal government.

Medicaid Coverage for Breast Reconstruction Surgery

The WHCRA of 1998 does not include the federal Medicaid program. Medicaid provides health insurance coverage to individuals and families with low income and no access to other resources. Each state is free to decide whether it includes breast reconstructive surgery as a covered benefit. Click here to go to the Medicaid website for West Virginia.

Breast Reconstruction Surgery and the Medicare Program

While Medicaid is an income-based program, Medicare is a program covering all people age 65 and older as well as some younger people with a permanent disability. One of the biggest complaints that Medicare users have about the program is that it can be complicated and difficult to understand. If you have Medicare, we encourage you to learn about your benefits at the start of your breast cancer treatment.

Breast prostheses worn after a mastectomy is covered by Medicare Part B. This is the portion of the program that offers medical insurance. Specialty bras are included in the category of breast prosthesis. Medicare Part B also covers your costs, less any deductible or co-insurance, if you have breast reconstruction surgery performed at an outpatient center. Medicare Part A kicks in for patients who are admitted to a hospital for breast reconstruction surgery.

Medicare requires a 20 percent co-payment for each breast prosthesis in addition to the physician’s fee. You can learn more about each part of Medicare at this page.

Reach Out to Your Cancer Patient Navigators with Additional Questions

We understand that insurance can be complex in the best of circumstances. When you’re dealing with the surgical removal of your breasts and reconstructive surgery, it can be downright overwhelming. Your cancer patient navigators are here to help. While they cannot make coverage decisions, they can help you understand your insurance benefits and provide referrals to additional resources if necessary.

Please note, the information provided throughout this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and video, on or available through this website is for general information purposes only. If you are experiencing related symptoms, please visit your doctor or call 9-1-1 in an emergency.