Short answer: The Women’s Health and Cancer Rights Act requires group and individual plans that cover mastectomies to also cover breast reconstruction, prostheses, and treatment of related complications such as lymphedema. Plans must notify members of these rights yearly.
The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that protects patients who have a mastectomy. If a group health plan or insurer covers mastectomies, it must also cover reconstruction of the breast that was removed, surgery on the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications at all stages, including lymphedema.
These benefits are provided in consultation with the patient and the attending physician, and they are subject to the plan’s normal deductible and coinsurance. Plans cannot deny coverage to avoid the requirements or offer inducements to a provider to do so.
Plans must notify enrollees of their WHCRA rights when they enroll and again each year. If you or a family member is facing a mastectomy, review your plan’s WHCRA notice and confirm how reconstruction and related care are covered before scheduling treatment.