Your Rights

Breast Reconstruction: Your Rights

A number of laws in the United States protect a woman’s right to obtain insurance coverage for breast reconstruction surgery. In addition, Federal law now also protects you against discrimination by health insurance companies and employers on the basis of genetic information such as BRCA status.

Federal Law and Breast Reconstruction

If you have had a mastectomy, or expect to have one, you should be aware of the Women’s Health and Cancer Rights Act of 1998 (WHCRA). This federal law insists that group health plans and individual health policies that provide coverage for mastectomies also provide coverage for breast reconstruction in connection with such mastectomy.

Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage also must provide coverage for certain services relating to the mastectomy in a manner determined in consultation with your attending physician and you. This required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, as well as surgery and reconstruction of the other breast to produce a symmetrical appearance.

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

Federal Antidiscrimination Law and Your Genetic Information

Some women have been afraid to proceed with elective treatment such as BRCA genetic testing or prophylactic mastectomy because they fear that the data about them—for example, that they are carriers of a genetic mutation that predisposes them to developing breast cancer—might be used against them on the job or in some other way. In fact, these recent U.S.laws provide protection against such mis-use of medical information.”]

On May 21st, 2008 the Genetic Information Nondiscrimination Act (GINA) was signed into Federal law. This law prohibits discrimination in health coverage and employment based on genetic information about an individual and the genetic information of family members. The GINA spells out unlawful practices in the use of genetic information for health insurers, employers, employment agencies, labor organizations, and employment training programs.

More specifically, GINA strictly prohibits the following:

Health Insurance Issues

• Health insurers may not require individuals to provide their genetic information or the genetic information of a family member to the insurer for eligibility, coverage, underwriting, or premium-setting decisions. However, a health insurer may request that an individual provide genetic information if coverage of a particular claim may be appropriate only if there is a known genetic risk—for example, if you want your insurance company to cover a prophylactic mastectomy because you have found that you are a carrier of the BRCA gene.
• Health insurers may not make enrollment or coverage decisions using genetic information collected either intentionally or incidentally.
• Health insurers may not request or require that an individual or an individual’s family member undergo a genetic test.
• In the Medicare supplemental policy and individual health insurance markets, genetic information cannot be used as a preexisting condition.

Employment Issues

• Genetic information may not be used in making decisions regarding hiring, promotion, terms or conditions, privileges of employment, compensation, or termination.
• An employer, employment agency, labor organization, or training program may not limit, segregate, or classify an employee or member, or deprive that employee or member of employment opportunities, on the basis of genetic information.
• An employer, labor organization, or joint labor-management committee may not use genetic information in making decisions regarding admission to or employment in any program for apprenticeship or training and retraining, including on-the-job training.

State Laws and Breast Reconstruction

In addition to the protections afforded by the Federal 1998 WHCRA, most states have laws pertaining to insurance coverage for breast reconstruction surgery.

Read more about your state’s laws.