Does Insurance Cover Breast Reconstruction? What to Know About Your Rights
Does insurance cover breast reconstruction? In many cases, yes. For most health plans that cover a mastectomy, a federal law called the Women’s Health and Cancer Rights Act requires coverage for reconstruction as well, though your usual copays, deductibles and plan rules still apply. October is Breast Cancer Awareness Month, so I want to explain in plain language what this law may mean for you, before you make any decisions.
Why So Many Women Ask: Does Insurance Cover Breast Reconstruction?
When you are facing a mastectomy, it is completely understandable that cost is one of your first concerns. It is one of the first questions women bring to me in consultation. Many worry that reconstruction will be treated as cosmetic and left out of their coverage.
I am a Double Board Certified Plastic Surgeon, and I have been performing breast reconstruction since 2008. In many cases, the law is on your side. Understanding your rights early can give you one less thing to worry about while you focus on your health.
What the Women’s Health and Cancer Rights Act Covers
The Women’s Health and Cancer Rights Act (WHCRA) is a federal law. For most plans that cover mastectomy, if you choose reconstruction, the plan must cover:
- All stages of reconstruction of the affected breast
- Surgery on the other breast to create symmetry
- Breast prostheses
- Treatment of physical complications, including lymphedema
“All stages” typically includes nipple reconstruction, areola tattooing and revisions, but each plan applies this in its own way. The benefit may also apply to a covered preventive mastectomy. Ask your insurer how each of these applies to you.
Reconstruction Is Covered Whether You Do It Now or Later
You do not have to decide everything before your mastectomy. Some women begin reconstruction at the same time as their mastectomy, while others wait months or even years. In many cases, reconstruction can still be covered if you choose to wait. Your plan’s rules at the time of surgery apply, so confirm with your insurer before you schedule.
If you are weighing your timing, my post on how long after mastectomy breast reconstruction can be performed walks through the options. My advice is simple: choose your timing based on your health and treatment plan, not on fear of losing coverage.
What Coverage Doesn’t Guarantee: Copays, Deductibles and Pre-Authorization
The law requires coverage, not full payment. Your plan’s usual copays, coinsurance and deductibles still apply, just as they would for any other surgery.
Many plans also require pre-authorization before surgery, and network rules can affect what you pay.
The law applies only when your plan covers the mastectomy itself. It does not require a plan to cover mastectomy in the first place. Some plans may be treated differently, and your state insurance department can tell you whether extra state-level protections apply to you.
Questions to Ask Your Insurance Company
A short call to your insurer can save you surprises later. Consider asking:
!Checklist of six questions to ask your insurance company about breast reconstruction coverage
- Is my mastectomy covered, and how does my plan apply the Women’s Health and Cancer Rights Act to reconstruction?
- Do I need pre-authorization, and who submits it?
- Are nipple reconstruction and tattooing covered?
- Is symmetry surgery on the other breast covered?
- What are my deductible, copay and coinsurance for surgery?
- Are there in-network requirements for my surgeon or surgical facility?
Plans are generally expected to describe this benefit in writing, so look through your enrollment and plan documents too. Only your insurer can confirm your own benefits, so write down the answers and bring them to your consultation.
Financing Options for Costs Insurance Doesn’t Cover
Even with coverage, some costs may remain. For those, my practice offers financing through Prosper Healthcare Lending. The terms include:
- Immediate decisions under $35,000
- Terms up to 60 months
- No collateral
- No prepayment penalties
Every woman’s situation is different, and your concerns about cost matter. My team and I are glad to talk through your options openly, so that questions about cost do not stand between you and feeling like yourself again.
Start With a One-on-One Consultation
Every procedure in my practice starts with a one-on-one consultation with me. We will talk about your goals, your treatment timeline and your reconstruction options, and I will help you think through the questions to bring to your insurer. As a female plastic surgeon, I understand how personal this decision is.
You can learn more about breast reconstruction in Phoenix or download my free Complete Guide to Understanding Breast Reconstruction. I want to help you be who you were before, in a relaxed, worry-free environment where your safety and comfort always come first.
*This article is general information, not legal or insurance advice. Please confirm your coverage directly with your health plan.*
Frequently Asked Questions
Is nipple reconstruction covered by insurance?
In many cases, yes. Under the Women’s Health and Cancer Rights Act, most plans that cover mastectomy must cover all stages of reconstruction. This typically includes nipple and areola reconstruction and tattooing. Check your plan to confirm your own coverage.
Will insurance cover surgery on my other breast for symmetry?
For most plans that cover mastectomy, the law requires coverage of surgery on the other breast to create symmetry. Depending on your needs, this might be a reduction or a lift. Pre-authorization and your plan’s cost-sharing may still apply.
Can I still get reconstruction covered years after my mastectomy?
In many cases, yes. Your plan’s rules at the time of surgery still apply, so check with your insurer before scheduling.
Does the law apply to a preventive mastectomy?
It may. The benefit is not limited to cancer treatment and can apply when your plan covers a preventive (prophylactic) mastectomy. Ask your insurer how your plan handles reconstruction in this situation.
What will I pay out of pocket for breast reconstruction after mastectomy?
That depends on your plan’s deductible, copays, coinsurance and network rules, so I cannot give a general figure. Your insurer can tell you your cost-sharing for surgery. We can also talk through financing options during your consultation.
If you have questions about breast reconstruction, I am here to help. Call (480) 963-3034 or contact our team to schedule a one-on-one consultation at my Chandler or Phoenix office. You can also download my free Complete Guide to Understanding Breast Reconstruction to read at your own pace.
