Breast Reconstruction Insurance: Laws by State
23 Nov 2016
Just like health insurance plans, laws and other legal mandates are confusing. I mean, there’s a reason people complete extra schooling to become lawyers. Laws are confusing! They have weird wording (why can’t they just be in normal English?!) and go through changes every once in awhile.
We’ve mentioned the Women’s Health and Cancer Rights Act of 1998 (WHCRA) before. This law applies to most insurance providers, and states that women receiving a mastectomy must have coverage for breast reconstruction. According to the WHCRA, coverage applies to all stages of breast reconstruction. It also includes surgeries needed for breast symmetry and treatment of physical complications.
Related to the WHCRA is the Breast Cancer Patient Education Act. Passed in December of 2015, it states that the Secretary of Health and Human Services must create an education campaign. The campaign teaches individuals about availability and coverage for breast reconstruction. To meet these requirements, HHS recently begun #choicetorebuild to reach women through social media.
That all sounds great, but what about breast reconstruction laws in your state?
As you may know, federal and state laws often differ from one another. Due to the Supremacy Clause, federal law should override state law, but this doesn’t always happen.
To help clear some of the confusion, we’re looking into how they play out in each state. In the coming months, we hope to complete our research and put it on a resources page. Until then, updates will be posted here.
What We Asked
We tried to find the answers to a few important questions. We developed these questions by looking at updates to state laws in Louisiana, which have been accomplished thanks to Breastoration. You can read more about Breastoration here. To get this information, we checked online resources and reached out to state insurance commissioners and legislators.
Here are the questions:
- Is there a legal duty to inform women about their right to breast reconstruction?
- Do immediate and delayed breast reconstruction legally have to be covered?
- How many stages of breast reconstruction must be covered, by law?
- Are cosmetic procedures to improve symmetry or nipple reconstruction covered?
- What about treatment procedures for things like flap failure or capsular contracture?
- Does state law dictate which breast reconstruction procedures women can get?
At first glance, it may seem like the answers to these
What We Found Out
As far as we can tell, all the states we contacted adhere to the laws set out in the Women’s Health and Cancer Rights Act for insurance providers.
We also found out that some medical clinics, such as Sanford Health (one of the largest health systems in North Dakota, Minnesota, and South Dakota) take it further and require that women who have had mastectomy be offered the opportunity to meet with a reconstructive and plastic surgeon.
Now onto the states!
We weren’t able to get information for every state. But we still have a pretty good mix to give you an idea of how states handle breast reconstruction.
In Alabama, all health insurance policies must follow federal insurance laws. The state requires compliance with such regulations as the Health Insurance Portability and Accountability Act of 1996 and the Women’s Health and Cancer Rights Act of 1998. The state’s Department of Insurance disapproves policies do not meet federal requirements.
We could not find any state laws in Colorado that addressed breast reconstruction.
When a group or blanket insurance policy covers mastectomy, it must cover breast reconstruction. This applies to insurance policies, certificates, and contracts. Coverage may be subject to coinsurance and annual deductibles. Written notice of this coverage must be delivered to the insured when they enroll and each year after.
These requirements follow the laws laid out in the WHCRA.
Delaware does prohibit coverage denials to avoid breast reconstruction costs. Further, breast reconstruction coverage must match coverage for other procedures.
Florida laws state that insurance providers must cover breast reconstruction. This coverage may be available as a rider or as part of the primary insurance contract. Applicants must be informed when applying if coverage is available through a rider. Just so you know, a rider is an add-on to a basic insurance. It offers extra benefits, but usually comes with an extra premium.
Further, the patient and treating physician choose the breast reconstruction procedure. It can be either immediate or delayed as long as it is consistent with current medical standards. This also means that all necessary stages of breast reconstruction are covered. The state defines breast reconstructive surgery as a procedure to reestablish symmetry between two breasts. This means coverage extends to symmetry procedures. But coverage is not guaranteed for nipple reconstruction. This also means that the law does not dictate which procedures women can get.
If any complications occur as a result of a covered procedure, the treatment for those complications are covered. Complications resulting from non-covered services are not always covered, even if those complications happen to be of a similar nature.
Georgia doesn’t have any state laws that require the coverage of breast reconstruction. But it does follow the WHCRA. Women in Georgia can receive coverage for breast reconstruction as long as their group or individual plan covers a mastectomy.
Georgia does ensure individuals receive notification of their coverage every year. Policyholders must receive yearly information packets that detail their insurance coverage.
We could not find any state laws in Hawaii that addressed breast reconstruction.
We could not find any state laws in Iowa that addressed breast reconstruction.
Women in Kansas receive coverage for breast reconstruction on the affected breast. They also receive coverage for symmetry procedures, prostheses, and procedures to treat physical complications. These requirements apply to all individual and group insurance policies providing benefits relating to mastectomy. Insured individuals cannot be denied coverage so providers can avoid breast reconstruction costs. Providers are also forbidden to reduce or limit reimbursement for breast reconstruction providers. Insured individuals must receive written notice of their coverage under the WHCRA.
All health benefit policies issued in Maryland must cover breast reconstruction. This applies to grandfathered individual health plans and large group health plans. The statute also applies to small group plans and non-grandfathered individual plans. This means all health insurance policies in the state must cover breast reconstruction.
The state law does not mention that women must receive any specific notice of this coverage. There is no time limit for when the procedure is done. Nor is there any limitation on the stages needed to complete breast reconstruction. State law also does not control which breast reconstruction procedures women can get. Coverage must also include all stages of reconstruction needed to establish symmetry, and all physical complications resulting from mastectomy are covered.
There are no extra laws in Massachusetts that apply to breast reconstruction. But the state follows the WHCRA.
Women in Michigan receive coverage for procedures that treat, improve the results of, or fix consequences of breast cancer. These procedures are either inpatient or outpatient services. They include such services as reconstructive plastic surgery, psychological services, and physical therapy.
For breast reconstruction procedures, timing, and cosmetic procedures, there are no legal state requirements. These areas vary depending on each individual woman’s insurance plan.
Minnesota law covers all stages of breast reconstruction for the breast removed due to mastectomy. Coverage also includes reconstructive surgery of the other breast for symmetry. The statute (62A.25) doesn’t say whether coverage includes both immediate and delayed reconstruction. But according to a representative of the insurance commissioner, coverage includes whatever the physician prescribes. As with the WHCRA, the law doesn’t apply to all policies, such as accident insurance policies.
We could not find any state laws in Mississippi that address breast reconstruction.
Based on New Hampshire’s statute, all insurers providing group or individual coverage for a mastectomy must cover all stages of breast reconstruction. Symmetry procedures are also covered, as are treatment procedures. Patients and their physicians are responsible for choosing the type of breast reconstruction procedure. The state does not have any restrictions on the type of breast reconstruction chosen.
We could not find any state laws in New Mexico that addressed breast reconstruction.
Follows with the WHCRA. The state proposed extra legislation. But the proposed laws were dismissed. This was likely because it reiterated the WHCRA.
We could not find any state laws in Ohio that addressed breast reconstruction.
According to the Oklahoma Breast Cancer Patient Protection Act, insurance providers must inform insured individuals of their coverage. Breast reconstruction is covered when total or partial mastectomy are the reason for reconstruction
The state regards breasts as a paired organ. So all stages of breast reconstruction are covered, along with procedures to establish symmetry. But this coverage is only protected for procedures done within 24 months of the original reconstruction.
Oregon requires that state insurance policies meet the requirements set out in the WHCRA. Aside from that, the state does not have its own set of laws about breast reconstruction.
Pennsylvania follows the WHCRA pretty closely. Insurance coverage must be provided for all health care policies that cover mastectomies. Those policies that cover mastectomy must cover treatment procedures, prosthetic devices, and breast reconstruction. The type of reconstruction procedure must be determined by the patient and their attending physician. So insurance providers cannot dictate which procedures are covered and which are not.
Notice of this coverage must also be sent by the insurance company.
The law defines reconstructive surgery as any surgical procedure performed on one or both breasts after a mastectomy. These procedures can be done to reestablish symmetry or correct functional problems caused by mastectomy. Thanks to this definition, women in Pennsylvania must be covered for symmetry procedures.
We could not find any state laws in South Dakota that addressed breast reconstruction, specifically.
We could not find any state laws in Vermont that addressed breast reconstruction, specifically.
Breast reconstruction in Virginia must be covered by providers offering group and individual accident and sickness policies. These policies must cover medical and surgical, hospital, or major medical coverage. Corporations providing group or individuals sickness and accidents contracts must also cover breast reconstruction. As do health maintenance organizations providing care plans for health care services.
Coverage for breast reconstruction must follow the same formula used for other surgical and medical procedures in the same plan. Time limits, deductibles, coinsurance, and dollar limits must also be the same as other procedures.
Virginia does require that insured individuals receive written notice of their breast reconstruction coverage. However, there is no clear legal duty that this requirement extends to physicians.
While the federal WHCRA only applies to group plans and plans that cover mastectomy services, Washington state laws extend to all insurance plans providing hospital or medical care.
According to the state, delayed and immediate breast reconstruction must be covered. This applies to women who have had a mastectomy resulting from injury, disease, or illness. All stages of breast reconstruction on the affected breast are covered. For the non-affected breast, at least one procedure to achieve symmetry is covered. The state does not dictate which breast reconstruction procedures a woman can receive.
Washington also requires that treatment procedures are covered by insurance. In this case, coverage is affected by whether a procedure is medically necessary. The necessary treatment must also be for a complication that is related to a mastectomy.
If you live in Washington and have any problems relating to your health insurance, please feel free to contact the Washington State Office of the Insurance Commissioner. The office can assist with questions and follow up with your insurance company to ensure they follow state laws.
Provides all that the WHCRA ensures. It also ensures coverage for any other related complications as determined in consultation with the attending physician.
Every disability insurance policy and every self-insured health plan that provides coverage of mastectomy shall provide coverage of breast reconstruction.
All insurance carriers in Wyoming must follow federal law when it comes to breast reconstruction. Any group and individual plan providing surgical and medical benefits for a mastectomy must also coverage breast reconstruction for the breast affected by the mastectomy. It must also cover symmetry and treatment procedures. Further, notice of coverage must be given to women.
Again, these are all just quick overviews regarding what state laws are in place regarding breast reconstruction. If you ever have a question about what coverage you have, check with your insurance provider. Should you feel that you are missing a legal protection that should be there, contact your state’s insurance commissioner or medical health authority.
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