Breast Reconstruction: Your Insurance Rights

Is breast reconstruction covered by insurance? Many women worry about how they’ll pay for reconstruction after a mastectomy or genetic risk assessment. Fortunately, several U.S. laws protect your right to obtain coverage, ensuring you can pursue the surgery you need without fear of discrimination or unexpected denials. Below, we summarize the key federal protections—including the Women’s Health and Cancer Rights Act (WHCRA) and the Genetic Information Nondiscrimination Act (GINA)—as well as note that most states offer additional safeguards.

Understanding the Women’s Health and Cancer Rights Act (WHCRA)

If you have had a mastectomy or are planning one, you should know about the 1998 WHCRA. This federal law mandates that group health plans and individual health policies covering mastectomies must also cover breast reconstruction related to that mastectomy.

Key Protections Under WHCRA

• Requires coverage for all stages of breast reconstruction on the breast that underwent a mastectomy.
• Guarantees coverage for surgery on the opposite breast if needed to achieve a symmetrical appearance.
• Ensures decisions on reconstruction are made in consultation with you and your attending physician.

Read the Women’s Health and Cancer Rights Act of 1998 (WHCRA).

Federal Antidiscrimination Law and Genetic Information

Some women hesitate to pursue BRCA genetic testing or a prophylactic mastectomy due to concerns about how insurers or employers might use their genetic data. However, federal law now protects you from such discrimination:

The Genetic Information Nondiscrimination Act (GINA), signed in 2008, prohibits health insurers and employers from using your genetic information against you. This includes any data that shows a heightened risk of certain cancers (e.g., BRCA mutations).

Health Insurance Protections

• Insurers cannot require you to provide genetic information for eligibility, coverage, or premium decisions.
• Insurers cannot deny coverage or make enrollment decisions based on genetic test results.
• While an insurer may ask for genetic proof to justify coverage of a preventive procedure (like prophylactic mastectomy), they cannot use that information to deny or limit coverage.

Employment Protections

• Employers cannot use genetic data to make decisions about hiring, firing, promotions, or compensation.
• Training programs and labor organizations cannot discriminate against members based on genetic details.

Read the Genetic Information Nondiscrimination Act (GINA)

State Laws Affecting Breast Reconstruction Coverage

In addition to WHCRA, most states have laws that further reinforce or expand coverage for breast reconstruction surgery. Requirements can vary, so it may help to review your state’s specific regulations or consult with our team at TPRSG for guidance.

Connecticut 

Provides coverage for the reasonable costs of reconstructive surgery on each breast on which a mastectomy has been performed, as well as reconstructive surgery on a non-diseased breast to create a symmetrical appearance.

New York 

Requires coverage for breast reconstruction following mastectomy, including reconstructive procedures on an unaffected breast if needed to achieve a reasonable symmetry, in a manner determined by the treating physician and patient.

Frequently Asked Questions

• Is breast reconstruction covered by insurance if I’ve had a mastectomy?
  Yes. Under WHCRA, any plan that covers mastectomy must also cover all stages of reconstructive surgery.
• Will my genetic test results affect my insurance or employment?
  No. Under GINA, insurers and employers cannot discriminate against you based on genetic information.
• Do these laws cover surgery on the other breast if I only had one mastectomy?
  Yes. WHCRA specifically requires coverage for procedures on the opposite breast to create symmetry.
• What about preventive (prophylactic) mastectomies?
  If your policy covers mastectomy, it must also cover reconstruction. Genetic risk alone (e.g., BRCA status) cannot be used to deny coverage.
• How can I confirm my coverage?
  We recommend contacting your health insurance provider or speaking with our team at TPRSG. We can help verify benefits and guide you through any necessary approvals.

Contact Us for Guidance

Still wondering “Is breast reconstruction covered by insurance?” We’re here to help. The team at TPRSG can assist you in understanding your plan’s benefits, exploring your legal rights, and ensuring you receive the coverage you deserve. Contact us today for personalized support.