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Breast Reconstruction Surgery

States can help breast cancer patients by mandating coverage for breast reconstruction after a mastectomy. Many patients have trouble getting coverage because some insurance companies deem it “cosmetic” surgery that is not medically necessary. Although a federal law was passed in 1998 to combat this practice, state laws add the strength of state enforcement mechanisms.1

Beginning in 2014, new health plans sold to individuals and small businesses will be required to cover a package of "essential health benefits." The law lists ten broad categories of services that will be among the essential benefits--including hospitalization and rehabilitative and habilitative services and devices--but the package will be further defined in the coming year by the Secretary of Health and Human Services. It is not yet clear whether breast reconstruction after mastectomy will be a required benefit.

Does the state require private insurers to cover breast reconstruction surgery?

States receive a "meets policy" if they provide broader coverage of reconstructive surgery following a mastectomy than is required by federal law. States receive a "no policy" if they do not have a coverage mandate for reconstructive breast surgery that is broader than federal requirements.

State Strength of Policy Change from 2007
Alabama No Policy Same
Alaska Meets Policy Same
Arizona Meets Policy Same
Arkansas Meets Policy Same
California Meets Policy Same
Colorado No Policy Same
Connecticut Meets Policy Same
Delaware Meets Policy Same
District of Columbia Meets Policy Same
Florida 2 Meets Policy Same
Georgia No Policy Same
Hawaii No Policy Same
Idaho No Policy Same
Illinois Meets Policy Same
Indiana Meets Policy Same
Iowa No Policy Same
Kansas Meets Policy Same
Kentucky Meets Policy Same
Louisiana Meets Policy Same
Maine Meets Policy Same
Maryland Meets Policy Same
Massachusetts No Policy Same
Michigan Meets Policy Same
Minnesota Meets Policy Same
Mississippi No Policy Same
Missouri Meets Policy Same
Montana Meets Policy Same
Nebraska Meets Policy Same
Nevada Meets Policy Same
New Hampshire Meets Policy Same
New Jersey Meets Policy Same
New Mexico No Policy Same
New York Meets Policy Same
North Carolina Meets Policy Same
North Dakota Meets Policy Same
Ohio No Policy Same
Oklahoma Meets Policy Same
Oregon Meets Policy Same
Pennsylvania Meets Policy Same
Rhode Island Meets Policy Same
South Carolina Meets Policy Same
South Dakota No Policy Same
Tennessee 3 No Policy Same
Texas Meets Policy Same
Utah Meets Policy Same
Vermont No Policy Same
Virginia Meets Policy Same
Washington 4 No Policy Same
West Virginia Meets Policy Same
Wisconsin Meets Policy Same
Wyoming No Policy Same

Policy Indicator Counts
Meets Policy: 
36
Limited Policy: 
0
Weak Policy: 
0
No/Harmful Policy: 
15
Better: 
0
Same: 
51
Worse: 
0

Data Source: The Henry J. Kaiser Family Foundation, "State Mandated Benefits: Reconstructive Surgery after Mastectomy," 2008, available at http://www.statehealthfacts.org/comparetable.jsp?ind=490&cat=10&sub=114&..., accessed April 13, 2010.

Footnotes

1 The Women’s Health and Cancer Rights Act, 29 U.S.C. § 1185b (1998); 42 U.S.C. §§ 300gg-6, 300gg-52 (1998).

2 Florida law allows the insurer to charge an "appropriate" additional premium for such coverage.

3 Tennessee should have received a "no policy" in 2007.  There is no actual change in state policy from the previous report card, thus no change is reported from 2007 to 2010.

4 Washington should have received a "no policy" in 2007.  There is no actual change in state policy from the previous report card, thus no change is reported from 2007 to 2010.

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