Insurance Information

Insurance companies are mandated by federal law to cover patients' procedure of choice in all cases of cancer patients who have had mastectomies, as well as surgery on the opposite breast to achieve symmetry.

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Insurance Coverage - Women's Health and Cancer Rights Act of 1998

On October 21, 1998, the Women's Health and Cancer Rights Act of 1998, became effective as part of the 1999 Omnibus Consolidated and Emergency Supplemental Appropriation Act. This new federal law requires group health plans and individual health policies that provide coverage for mastectomies to also provide coverage for breast reconstruction in connection with such mastectomy.In accordance with the Women’s Health and Cancer Rights Act of 1998, members receiving mastectomy-related services are entitled to the following benefits:

  • reconstruction of the breast on which the mastectomy has been performed;
  • surgery and reconstruction of the other breast to produce a symmetrical appearance;
  • prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas;
  • one home health care visit within 48 hours of hospital discharge;
  • outpatient care following a mastectomy performed in a health care facility; and
  • inpatient and skilled nursing facility care in which the length of stay is determined by the treating physician based upon generally accepted criteria for safe discharge.

This coverage will be provided in a manner determined in consultation with the attending physician and the patient. These benefits are subject to any deductible or coinsurance requirements that may apply to your coverage.

Insurance Coverage - State Laws

Insurance Coverage is Required for Post-Mastectomy Breast Reconstruction if Mastectomy is Covered.Alaska: enacted in 2000; conforms state law to the federal standards. The bill directly refers to the specific federal requirement: (A health care insurer that offers, issues for delivery, delivers, or renews in this state a health care insurance plan providing medical and surgical benefits for mastectomies shall comply with 42 U.S.C. 300gg-6 and 42 U.S.C. 300gg-52 regarding coverage for reconstructive surgery following mastectomies).Arizona: enacted in 2000; conforms state law to the federal standards. The bill directly refers to the specific federal requirement: (A health care insurer that offers, issues for delivery, delivers, or renews in this state a health care insurance plan providing medical and surgical benefits for mastectomies shall comply with 42 U.S.C. 300gg-6 and 42 U.S.C. 300gg-52 regarding coverage for reconstructive surgery following mastectomies).Arkansas: enacted in 1997; covers prosthetic devices and reconstructive surgery.

California: enacted in 1978; covers prosthetic devices or reconstructive surgery incident to mastectomy, including restoring symmetry; law was amended in 1991 to include coverage for pre-1980 mastectomies.

Connecticut: enacted in 1987; covers at least a yearly benefit of $500 for reconstructive surgery, $300 for prosthesis, and $300 for surgical removal of each breast due to tumor.

Delaware: enacted 2001; covers all stages of breast reconstruction including surgery and reconstruction of the opposite breast to produce symmetry; includes language stating surgery shall be provided in a manner determined in consultation with the attending physician.

Florida: enacted in 1987; covers initial prosthetic device and reconstructive surgery incident to mastectomy; 1997 amendment states that the surgery must be in a manner chosen by the treating physician, and surgery to reestablish symmetry is covered.

Illinois: initially enacted in 1980; covers initial prosthetic device and reconstructive surgery incident to post-1981 mastectomies. New bill enacted 2001 brings state into Federal compliance with federal requirements of the 1998 Womens' Health and Cancer Rights Act

Indiana: enacted in 1997; covers prosthetic devices and all stages of reconstructive surgery, in the manner determined by the attending physician and patient, including reconstruction of the other breast to produce symmetry. Additional legislation enacted in 2002 requires coverage for post-mastectomy services regardless of whether the individual was covered under the policy at the time of the mastectomy.

Kansas: enacted in 1999; covers breast reconstruction, including surgery of the other breast to produce a symmetrical appearance, prostheses and physical complications, in a manner determined in consultation with the attending physician and the patient.

Kentucky: enacted in 1998; covers all stages of breast reconstruction surgery following a mastectomy that resulted from breast cancer. 2002 amendment conforms statute to federal law

Louisiana: enacted in 1997; covers reconstructive surgery following a mastectomy, including reconstruction of the other breast to produce a symmetrical appearance, as agreed by the patient and attending physician. 1999 amendment conforms statute to federal law.

Maine: enacted in 1995; covers both breast on which surgery was performed and the other breast if patient elects reconstruction, in the manner chosen by the patient and physician.

Maryland: enacted in 1996; requires coverage for reconstructive surgery resulting from a mastectomy, including surgery performed on a non-diseased breast to establish symmetry.

Michigan: enacted in 1989; covers breast cancer rehabilitative services, delivered on an inpatient or outpatient basis, including reconstructive plastic surgery and physical therapy.

Minnesota: enacted in 1980; covers all reconstructive surgery incidental to or following injury, sickness or other diseases of the involved part, or congenital defect for a child. Additional legislation enacted in April 2002 expands language to specifically include benefits for all stages of reconstruction following mastectomy consistent with federal law. Also specifies that limitations on reconstructive surgery do not apply to reconstructive breast surgery following medically necessary mastectomy.

Missouri: enacted in 1997; covers prosthetic devices and reconstructive surgery necessary to achieve symmetry, as recommended by the oncologist or primary care physician.

Montana: enacted in 1997; covers reconstructive surgery following a mastectomy resulting from breast cancer, including all stages of one reconstructive surgery on the non-diseased breast to establish symmetry, and costs of any prostheses.

Nebraska: enacted in March 2000; follows the example of the federal statute by requiring coverage for medical and surgical benefits for mastectomy and for all stages of reconstruction of the breast after a mastectomy has been performed and reconstruction of the other breast to produce a symmetrical appearance. The measure also requires coverage for prostheses and physical complications of mastectomy.

Nevada: enacted in 1983; covers at least two prosthetic devices and reconstructive surgery incident to mastectomy. The law was amended in 1989 to cover surgery to reestablish symmetry.

New Hampshire: enacted in 1997; covers breast reconstruction, including surgery and reconstruction of the other breast to produce a symmetrical appearance, in the manner chosen by the patient and physician.

New Jersey: enacted in 1985; covers reconstructive breast surgery, including cost of prostheses. The law was amended in 1997 to extend coverage to reconstructive surgery to achieve and restore symmetry.

New York: enacted in 1997: covers breast reconstruction following mastectomy, including reconstruction on a healthy breast required to achieve reasonable symmetry, in the manner determined by the attending physician and the patient to be appropriate.

N. Carolina: enacted in 1997; covers for reconstructive breast surgery, including all stages and revisions of surgery performed on a non-diseased breast to establish symmetry, and reconstruction of the nipple/areolar complex without regard to the lapse of time between mastectomy and reconstruction. (1999 amendment conforms statute to federal law: Not Carried Over to 1999 General Assembly Second Session.)

N. Dakota: enacted 2001; specifies that health insurance policies may not be issued or renewed in the state unless they provide the benefit provisions of the 1998 Federal Womens' Health and Cancer Rights Act.

Oklahoma: enacted in 1997; covers reconstructive breast surgery performed as a result of a partial or total mastectomy, including all stages of reconstructive surgery performed within 2 years on a non-diseased breast to establish symmetry.

Pennsylvania: enacted in 1997; covers prosthetic devices and breast reconstruction, including surgery on the opposite breast to achieve symmetry, within six years of the mastectomy date. Additional legislation enacted 2002 adds language consistent with federal law.

Rhode Island: enacted in 1996; covers prosthetic devices and reconstructive surgery to restore and achieve symmetry incident to a mastectomy. Surgery must be performed within 18 months of the original mastectomy.

S. Carolina: enacted in 1998; covers prosthetic devices and breast reconstruction, including the non-diseased breast, if determined medically necessary by the patient and attending physician with the approval of the insurer.

Tennessee: enacted in 1997; covers all stages of reconstruction for the diseased breast, excluding lumpectomy, and procedures to restore and achieve symmetry between the breasts, in the manner chosen by the patient and physician, within 5 years of the reconstructive surgery on the diseased breast.

Texas: enacted in 1997; covers reconstruction of the breast incident to mastectomy, including procedures to restore and achieve symmetry, for contracts delivered, issued for delivery or renewed on or after Jan. 1, 1998. 1999 amendment conforms statute to federal law.

Utah: enacted in 2000; follows the example of the federal statute by requiring coverage for medical and surgical benefits for mastectomy and for all stages of reconstruction of the breast after a mastectomy has been performed and reconstruction of the other breast to produce a symmetrical appearance. The measure also requires coverage for prostheses and physical complications of mastectomy.

Virginia: enacted in 1998; covers reconstructive breast surgery performed coincident with a mastectomy performed for breast cancer or following the mastectomy, and surgery performed to reestablish symmetry between the two breasts.

Washington: enacted in 1985; covers reconstructive breast surgery if mastectomy resulted from disease, illness or injury. The law was amended in 1996 to include surgery to reestablish symmetry.

West Virginia: Enacted 2002, includes coverage for reconstruction of the breast on which mastectomy was performed and the opposite breast for symmetry; also provides coverage for prosthesis and complications all as determined in consultation with attending physician and patient.

Wisconsin: enacted in 1997; covers breast reconstruction of the affected tissue incident to mastectomy and specifies that such surgery is not considered cosmetic.




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