Breast Reconstruction – Do You know All of Your Essential Rights?

By Heather Karu, MD Jul 27, 2016

Know your rights reconstruction rights

Your first right after a mastectomy is to have coverage for reconstruction. The Women’s Health and Cancer Rights Act of 1998 (WHCRA) ensured this. Under this act, IF your group health plan covers your mastectomy (whether related to cancer or not, i.e. if you are having the mastectomy due to high risk), the plan MUST provide reconstructive surgery and other post-mastectomy benefits. This coverage includes all stages of reconstruction of the breast on which the mastectomy was performed AND ALSO reconstruction of the other breast to produce symmetry. Other required coverage includes prostheses and treatment of physical complications related to the mastectomy such as lymphedema.

This means that your plastic and reconstructive surgeon can offer a patient reconstruction without hesitation. Most importantly, there is no time limit or expiration. Also, if a patient develops asymmetry either immediately or over time, the plastic and reconstructive surgeon is able to offer revisions to achieve and maintain symmetry.

Unfortunately, there are some exclusions. Certain plans that are government or church related plans may NOT be subject to this law; however, it is rare for a plan to deny you your coverage.

Some very helpful resources for you are the United States Department of Labor website: www.dol.gov/ebsa/publications/whcra.html; the website linked to the Patient Protection and Affordable Care Act (ACA) site: www.dol.gov/ebsa/healthreform/consumer.html ; and the Department of Health and Human Services site: www.HealthCare.gov.
While the Women’s Health and Cancer Rights Act is instrumental in providing coverage, nationally less than half of all women requiring a mastectomy are currently offered breast reconstruction surgery. Additionally, fewer than one in five elect to undergo the procedure. A recent study in the Journal of the American Medical Association sadly identified that almost one-fifth of women who do not undergo breast reconstruction reported a lack of knowledge regarding the procedure.

Have we made any recent progress? Absolutely! On December 18th, 2015, Congress passed the Breast Cancer Patient Education Act. This Act requires the Secretary of Health and Human Services to plan and implement an education campaign to inform breast cancer patients about the availability and coverage of breast reconstruction and other available alternatives post-mastectomy.

I am fortunate to work at Sanford Health which directs that every mastectomy patient is offered the opportunity to meet with a plastic and reconstructive surgeon. My sincere hope is that this information will assist in empowering women with the knowledge to make an informed decision.

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