Life Insurance Options Post-Mastectomy: What You Need To Know

The Women's Health and Cancer Rights Act of 1998 (WHCRA) provides protections for patients who choose to have breast reconstruction after a mastectomy. This includes coverage for all stages of reconstruction, surgery to produce a symmetrical appearance, and treatment of physical complications. While the WHCRA does not require insurers to cover mastectomies in general, if an insurer chooses to do so, they are subject to the WHCRA requirements. This means that those who have had a mastectomy may be entitled to special rights and protections under the WHCRA when it comes to life insurance and other benefits.

The Women's Health and Cancer Rights Act (WHCRA)

The WHCRA requires group health plans and health insurance companies, including HMOs, to notify individuals about the coverage required under the law. This notice must be given to participants and beneficiaries of a group health plan when they enrol, and annually thereafter. It must also be given to policyholders when an individual health insurance policy is issued, and annually thereafter.

The WHCRA does not require group health plans or health insurance issuers to cover mastectomies in general. However, if a group health plan or health insurance issuer chooses to cover mastectomies, they are generally subject to WHCRA requirements. These requirements include coverage for:

• All stages of 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 of all stages of the mastectomy, including lymphedema

The WHCRA also prohibits "drive-through" mastectomies, where breast cancer patients' hospital stays are limited by their carriers. Additionally, the law requires coverage for second opinions, in or out of network, for all cancer patients, allowing them to visit a major cancer centre if they choose.

The WHCRA is administered by the U.S. Departments of Labor and Health and Human Services. For more information about your rights under the WHCRA, individuals can contact the Department of Labor or the Employee Benefits Security Administration of the Department of Labor.

Breast reconstruction surgery

There are several types of breast reconstruction surgery, which can be done immediately after a mastectomy or months or years later. Some techniques use implants, while others use tissue from the patient's body, such as the belly, thigh, back, or buttocks, to form a new breast.

Implant Reconstruction

Implant reconstruction involves using saline or silicone implants to recreate breast tissue. Sometimes, surgeons may also use a combination of implants and tissue from the patient's body. The implant may be placed under or above the chest muscle. In some cases, a tissue expander is used to stretch the skin before inserting the implant.

Flap Reconstruction

Flap reconstruction uses tissue from the patient's own body (autologous tissue) to form a new breast. This tissue, called a flap, can include fat, skin, blood vessels, and sometimes muscle. The flap can be moved to the breast area while keeping its blood supply intact (pedicled flap), or it can be detached from its blood supply and attached to blood vessels in the chest (free flap).

The different types of flap reconstruction include:

• DIEP flap: Skin, fat, and blood vessels are taken from the lower belly, without removing the underlying abdominal muscle.
• TRAM flap: Skin, fat, blood vessels, and muscle are removed from the lower belly.
• Latissimus dorsi (LD) flap: Tissue and muscle are removed from the back and transplanted to the breast area while keeping the blood supply intact.
• IGAP flap: Tissue, including fat, blood vessels, and skin, is taken from the buttocks, without using muscle.
• SGAP flap: Similar to the IGAP flap, but uses a different set of blood vessels.
• PAP flap: Tissue is taken from the inner and back of the thigh, without transplanting muscle.
• TUG flap: Tissue and muscle are taken from the upper inner thigh.
• SIEA flap (or SIEP flap): Similar to the DIEP flap but uses different blood vessels. This technique is less common due to the specific blood vessels required.

Nipple and Areola Reconstruction

In some cases, the nipple and areola may be preserved during the mastectomy. If they are removed, they can be reconstructed using tissue from another part of the body (skin graft) or local skin on the breast. The colour can be added using tattoo ink, creating a realistic image of an areola.

Timing of Reconstruction

The timing of breast reconstruction surgery depends on the patient's preferences, medical conditions, and cancer treatment. It can be done during the mastectomy or delayed until after chemotherapy or radiation treatments are completed.

Advantages of Breast Reconstruction Surgery

Risks and Complications

As with any surgery, there are risks and complications associated with breast reconstruction. These include infection, bleeding, bruising, scarring, and fat necrosis (death of transplanted tissue). Implants may also cause complications such as wrinkling, rippling, or ruptures. There may also be weakness, pain, or sensitivity at the donor site after flap reconstruction.

Coverage for mastectomies

The Women's Health and Cancer Rights Act of 1998 (WHCRA) provides protections for patients who choose to have breast reconstruction in connection with a mastectomy. This federal law applies to group health plans and health insurance companies (including HMOs) that cover mastectomies, requiring them to also cover the following:

• Reconstruction of the breast that was removed by mastectomy, including all stages of reconstruction.
• Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced.
• Any external breast prostheses needed before or during reconstruction.
• Treatment of physical complications at all stages of the mastectomy, including lymphedema (fluid build-up in the arm and chest on the side of the surgery).

It's important to note that WHCRA does not require insurers to cover mastectomies themselves, but if they choose to, they become subject to the above requirements. This law also mandates that insurance providers notify you of this coverage when you enroll and every year after that.

While WHCRA provides protections for those seeking breast reconstruction after a mastectomy, it does not cover all situations. Certain "church plans" and "government plans" may be exempt from paying for reconstructive surgery. If you are insured under one of these plans, consult your plan administrator for more information. Additionally, WHCRA does not apply to Medicare and Medicaid, although Medicare will cover breast reconstruction following a mastectomy due to breast cancer.

For those without insurance coverage for a mastectomy, there are other options to consider. Federally qualified health centers, Hill-Burton facilities, and the Patient Advocate Foundation offer financial assistance and resources for individuals needing help with their medical expenses.

Deductibles and coinsurance

Under the Women's Health and Cancer Rights Act of 1998 (WHCRA), if your group health plan or health insurance company covers mastectomies, they are required to provide certain reconstructive surgery and other benefits related to the mastectomy. This includes all stages of breast reconstruction, surgery to achieve symmetry between the breasts, and treatment of physical complications of the mastectomy, such as lymphedema.

While WHCRA provides important protections, it does not specify that these procedures must be covered in full. Deductibles and coinsurance may apply, but these should be no more than those established for other benefits under the plan. In other words, the deductible for post-mastectomy reconstructive surgery should be similar to the deductible for any comparable procedure covered by the plan.

Deductibles

A deductible is the initial amount you are required to pay out-of-pocket before your insurance company starts contributing to your healthcare costs. For example, if you have a $2,000 deductible, you will need to pay that amount in full before your insurance company will begin covering a portion of your medical expenses. Certain preventive services, such as routine check-ups, vaccines, and screenings, may be exempt from deductibles.

Coinsurance

Coinsurance is the percentage of covered health costs that you are responsible for paying after you have met your deductible. Coinsurance plans typically operate on a fixed ratio, meaning you will always be charged the same percentage of the total bill each time. For example, under an 80/20 coinsurance plan, your insurance company pays 80% of the cost, and you pay the remaining 20%.

Coinsurance rates may vary depending on whether a provider is in-network or out-of-network. Out-of-network care may have higher coinsurance rates, and in some cases, your insurance provider may not cover any of the costs for out-of-network services. Therefore, it is important to carefully review the coinsurance rates and policies of your insurance plan.

Out-of-Pocket Maximum

Your coinsurance payments contribute to your out-of-pocket maximum. Once you reach this maximum limit, you will stop paying coinsurance, and your insurance company will cover 100% of the remaining costs for covered services.

Health insurance appeals

If you have had a mastectomy, you may be entitled to special rights under the Women's Health and Cancer Rights Act of 1998 (WHCRA). This law provides protections to patients who choose to have breast reconstruction in connection with a mastectomy. If your health insurance company covers mastectomies, it must also provide certain reconstructive surgery benefits and other post-mastectomy care. This includes:

• All stages of breast reconstruction, including acellular dermal matrix products, nipple/areolar reconstruction and tattooing, and revision surgery.
• Surgery to achieve symmetry between the breasts, including possible reduction or lift of the healthy breast.
• Prostheses and treatment of physical complications of the mastectomy, including lymphedema.

It is important to note that WHCRA does not require 100% coverage, so copays, coinsurance, and deductibles may apply. Additionally, some insurers may limit coverage to in-network providers. If your insurance company denies coverage for mastectomy or breast reconstruction, you can file a health insurance appeal. Here are some steps to consider when appealing a health insurance decision:

• Understand your health insurance plan: Review your plan documents, including the summary plan description (SPD), to understand your coverage, benefits, and any exclusions or limitations.
• Gather supporting documentation: Collect all relevant medical records, doctor's reports, and other information that supports your case for coverage. This may include letters of medical necessity from your surgeons and other healthcare providers explaining your high-risk status.
• Contact your insurance company: Reach out to your insurance company to clarify their specific appeal process and any required forms or documentation. Ask for a detailed explanation of why your claim was denied and request a review of your case.
• Utilize resources: Visit the Health Insurance Appeals section of the FORCE website (facingourrisk.org) for guidance and resources. They provide downloadable sample appeal letters that you can use as a starting point. You can also contact the Patient Advocate Foundation, which helps individuals identify financial assistance programs and resources.
• File the appeal: Follow the instructions provided by your insurance company to file the appeal. Provide all the necessary documentation and clearly state your reasoning for why the claim should be covered.
• Seek external review: If your insurance company upholds the denial, you may have the option to request an external review by an independent third party. This process may vary depending on your state and insurance plan.

Remember, it is important to act promptly when filing an appeal, as there may be time limits involved. Keep detailed records of all communications and responses received during the process.

Frequently asked questions