Blue Cross HMO, California, and coverage for implants?

heather214

Hello,

This is a little pre-emptive, newly diagnosed and awaiting double mastectomy (one prophylactic). A huge fear, because I have already been struggling with them, is knowing if reconstruction on either breast will be covered. Does anyone have experience with BCBS/California and is there a time limit as to when I must have reconstruction by? Thank you!

cinnamonsmiles

I copied this from cancer.org, The American Cancer Society website, for you:

Women’s Health and Cancer Rights Act

The Federal law

The Women’s Health and Cancer Rights Act (WHCRA) helps protect many women with breast cancer who choose to have their breasts rebuilt (reconstructed) after a mastectomy. This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law.

The WHCRA:

• Applies to group health plans for plan years starting on or after October 1, 1998
• Applies to group health plans, health insurance companies, and HMOs, as long as the plan covers medical and surgical costs for mastectomy

Under the WHCRA, mastectomy benefits must cover:

• Reconstruction of the breast that was removed by mastectomy
• Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy
• Any external breast prostheses (breast forms that fit into your bra) that are needed before or during the reconstruction
• Any physical complications at all stages of mastectomy, including lymphedema (I am adding that not all cover gloves and sleeves...it was left out of mandatory coverage when the law was made.)

Mastectomy benefits may have a yearly deductible and may require that you pay co-insurance. Co-insurance is when health costs are insured for less than the full amount and the patient must pay the difference.

For instance, the company may cover 80% of your expenses after you pay the deductible, leaving you to pay the other 20%. This 20% is also called a co-payment or co-pay. But any required deductible and co-insurance must be like those the plan uses for other conditions it covers. So, if a plan pays 80% for hospital and surgery fees for an appendectomy, but only 70% of hospital and surgery fees for breast reconstruction, that would violate the WHCRA.