Reconstructive Surgery is Fully Covered after Mastectomy

Notice of Women’s Health and Cancer Rights Act of 1998

Millions of Americans mistakenly believe that HMOs and other group health plans never cover procedures often referred to as “plastic surgery.” That is incorrect.

Some procedures are, of course, classified as cosmetic and, therefore, not covered. However, women who undergo mastectomies are entitled to reconstructive surgery as part of the HMO’s or group health plan’s comprehensive benefits package.

Benefit details

The Women’s Health and Cancer Rights Act of 1998 established standards for this benefit, which previously varied from carrier to carrier.

In the case of a participant or beneficiary who is receiving benefits under the plan in connection with a mastectomy and elects reconstruction, federal law requires coverage, in a manner determined in consultation with the attending physician and the patient, for:

• Reconstruction of the breast on which the mastectomy was 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 lymphedema.

This coverage is subject to the plan’s annual deductible and co-insurance provisions.