Coverage of complications & revisions

If a group health insurer covers mastectomy, the Women’s Health and Cancer Rights Act (WHRCA) stipulates that most plans cover all stages of reconstruction of the breast(s) on which a mastectomy was performed. This includes coverage of care related to mastectomy or breast reconstruction complications including, but not limited to, infection, capsular contracture and implant rupture. WHRCA also provides for reasonable and necessary revisions to correct physical or aesthetic problems. 

WHRCA does not require 100% coverage by health insurance so copays, coinsurance and deductibles may apply. Some group health insurers limit coverage to in-network providers or use a less-favorable reimbursement formula for out-of-network providers. 

Medicare & Medicaid

Medicare and Medicaid are public programs that are not bound by the WHRCA. They have their own rules. Medicare covers breast reconstruction after a "medically necessary" mastectomy typically associated with a cancer diagnosis, while Medicaid coverage varies by state.

See the Insurance & Paying for Care section of our website for more information.

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